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Clinical and Educational Child Psychology
Clinical and Educational
Child Psychology
An Ecological-Transactional Approach
to Understanding Child Problems
and Interventions
Linda Wilmshurst
A John Wiley & Sons, Ltd., Publication
This edition first published 2013
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Library of Congress Cataloging-in-Publication Data
Wilmshurst, Linda.
Clinical and educational child psychology : an ecological-transactional approach to understanding
child problems and interventions / Linda Wilmshurst.
p. cm.
Includes index.
ISBN 978-1-119-95226-8 (cloth) – ISBN 978-1-119-95225-1 (pbk.) 1. Developmental
psychology. 2. Child psychology. 3. Clinical child psychology. I. Title.
BF713.W55 2013
618.92 89–dc23
2012029604
A catalogue record for this book is available from the British Library.
C Cathy Yeutet / 123RF
Cover image: Photo Cover design by www.cyandesign.co.uk
Set in 10/12 pt Galliard by Aptara Inc., New Delhi, India
1 2013
Contents
Part One
The Foundations
1 Child and Adolescent Development: Normal and Atypical Variations
2 Theoretical Models
3
23
3
Developmental Milestones: Early and Middle Childhood
54
4
Developmental Milestones: Adolescence
84
5
Development from a Clinical and Educational Perspective
Part Two
106
Child and Adolescent Problems and Disorders
6
Adjustment Problems and Disorders in Childhood and Adolescence
135
7
Early Onset Problems: Preschool and Primary School
162
8
Problems of Learning and Attention
192
9
Externalizing Problems and Disruptive Behavior Disorders
219
10
Internalizing Problems and Anxiety, Mood, and Somatic Disorders
242
11
Later Onset Problems: Eating Disorders and Substance Use/Abuse
276
12
Child Maltreatment and Self-Injurious Behaviors
301
13
Trauma and Trauma Disorders
328
Index
354
Part One
The Foundations
Clinical and Educational Child Psychology, First Edition. Linda Wilmshurst.
© 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.
1
Child and Adolescent
Development: Normal and
Atypical Variations
Introduction
What is normal behavior and when does
deviation from the norm become serious enough to warrant a label of “abnormal” behavior? Can behavior be considered
normal in one context and abnormal in
another? Can behavior be considered “normal” at one age and “abnormal” or atypical
at another age? These are some of the questions that will be addressed throughout this
book and in the case study in this chapter.
A case in practice
Case study of Pat: an
introduction
Pat is experiencing problems in school. Pat never seems to finish assignments on time and takes forever to
get started on a task. Yesterday, Pat
sat for 15 minutes staring into space,
before putting pencil to paper.
When Pat enters the classroom,
you can tell immediately if it is going
to be a good day or a bad day. One
day, Pat can be moody, irritable, and
very hard to get along with, and on
another day, Pat can be happy and
almost giddy with excitement. However, on these occasions, it is very easy
for Pat to escalate out of control.
Because of the mood swings, Pat is
not popular with peers, and basically
has no friends, at school. As a result,
Pat is often on the sidelines watching
as others socialize and have fun.
Fortunately, Pat is a member of
the community soccer team, which
affords an opportunity to engage in
activities with peers on the weekend.
As you read the case study in the sidebar,
ask yourself the question: “How serious is
Pat’s problem?” Pat is experiencing problems in a number of different areas, including social, emotional, and educational. If
you were a clinical or educational/school
psychologist, and Pat’s mother or teacher
asked if you thought Pat was in need of
intervention, how would you determine
the severity of Pat’s problems and what
important information would you need to
know? What is the first question you should
ask? The first question should be: How old
is Pat? Because children are growing and
changing, it is imperative to know what the expectations are for Pat, given the age
level. If Pat were a preschooler, the mood swings would likely be due to immaturity in emotional control and emotion regulation which is in the process of being
Clinical and Educational Child Psychology, First Edition. Linda Wilmshurst.
© 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.
4
Clinical and Educational Child Psychology
Table 1.1
1.
2.
3.
4.
5.
Guideposts to the study of child development
Development unfolds in a predictable pattern.
Patterns of behavior and skills (thoughts, emotions, motor skills) build upon previously
acquired skills and progress towards increasingly complex variants of these behaviors
throughout childhood and adolescence.
Although children pass through similar stages or sequences of development, the rate of
mastery of various milestones can vary widely due to individual differences.
Some factors that can influence a child’s rate of skill acquisition, for better or worse,
include: child variables, such as heredity, temperament, cognitive ability, motor, affective,
and social maturation; and environmental variables, such as parenting practices,
socio-economic status, peers, quality of schooling, culture, as well as availability of and access
to community resources. As a result, development is the outcome of the on-going
transactions between the child and his or her environment.
In the transactional model (Sameroff & Chandler, 1975), child and parent outcomes
are seen to be the result of the on-going interplay of child and environmental factors that
influence, respond to, and adapt to changes on several ecological levels (Bronfenbrenner,
1979). The application of these models as an over-arching framework for understanding
child development across biological, psychological, and social domains has resulted in a
complex and comprehensive perspective: the ecological transactional model (Cicchetti
& Lynch, 1993).
stabilized during this period. However, if Pat is an eight- or 10-year-old child, then our
expectation would be for significantly more maturity in areas of emotional control and
self-regulation. Additionally, the age of the child would determine which assessment
instruments should be used and the type of pre-assessment information that might
be useful. Initially, regardless of the focus of concern, understanding the problem
requires a fundamental understanding of the nature and course of development.
The nature and course of development
The study of human development in the formative years focuses on predictable
“age-related changes that are orderly, cumulative and directional” (DeHart, Sroufe,
& Cooper, 2004, p. 4). Knowledge of normal development is a prerequisite to understanding the extent and nature of any deviations from the norm that may exist in
social, emotional, or behavioral functioning. In normal development, skills and competencies build on previous foundations, becoming increasingly refined and complex.
It is from this predictable framework that deviations in the acquisition of developmental milestones (physical, cognitive, behavioral, emotional, social) can be assessed using
normal developmental expectations as the guide.
There are several guiding principles from the study of normal development that
have significant implications for understanding deviations in child development from
a clinical and educational perspective. Some of the salient features are presented in
Table 1.1.
Transactional processes
The term “transactional” is used to refer to the “interrelations among
dynamic biological, psychological and social systems” that provide the necessary
Child and Adolescent Development: Normal and Atypical Variations
5
framework for the “ongoing and multiple transactions among environmental
forces, caregiver characteristics and child characteristics as dynamic, reciprocal
contributions” that increase or decrease the likelihood of well-being or psychopathology (Cicchetti & Toth, 1998, p. 226).
The nature of developmental change
Historically, developmental change has been conceptualized as following either a
discontinuous or continuous course, while the major contributing forces have been
attributed to the influences of nature (heredity) or nurture (environment). Within this
framework, outcomes in the form of milestones or benchmarks assist in making comparisons between levels of achievements mastered relative to predicted developmental
expectations. The following discussion looks at how theorists have conceptualized the
nature of developmental change over time.
Discontinuous versus continuous change
Discontinuous change Theorists who propose a discontinuous pathway conceptualize development as a series of steps or stages which involve the mastery of levels that are distinctively different at each stage. Theoretical models that share this
framework include, but are not limited to: Piaget’s stages of cognitive development,
Freud’s psychosexual stage theory, and Erikson’s stages of psychosocial development.
Within this framework, theorists view change as quantitative and universal with a
consistent set of sequences and a fixed order of progression, regardless of cultural or
global context.
Continuous change Other theorists believe that developmental change progresses
in a smooth and continuous manner. For example, information processing theorists
would be interested in studying how a child’s memory strategies evolve over time,
as the child adds new strategies and skills to his or her repertoire. Memory strategies
adopted later in development would be qualitatively different from earlier methods
used and would build on earlier skill sets. Within this framework, behavioral theorists
would also consider the development of behavioral patterns as a continuous process
of increasingly complex skills that build upon earlier patterns.
Nature versus nurture: historical beginnings One of the most controversial themes
surrounding child development that has sparked endless debate is the relative contribution of nature (heredity) versus nurture (environment).
Nature On one side of the historical debate, the eighteenth-century French philosopher Jean-Jacques Rousseau challenged assumptions regarding the importance of the
environment for one’s development and argued that nature was the supreme influence
over the course of development. According to Rousseau, if parents were to adopt a
laissez-faire approach (leaving the child alone and not interfering), the child would
unfold naturally and blossom like a flower. For Rousseau, development was best represented as a series of stages (infancy, childhood, late childhood, and adolescence)
that were programmed to unfold in a predictable pattern (discontinuous process).
6
Clinical and Educational Child Psychology
Nurture On the other side of the debate, proponents supported the views of the
seventeenth-century English philosopher John Locke, who argued for the importance
of “nurturance” in child rearing. According to Locke, children begin their existence as
a tabula rasa, or blank slate, and are dependent on those around them to nurture their
existence by filling their slates with knowledge. Locke would have been supportive
of change as a continuous process, evident in the increasingly complex changes that
result under the tutelage of adult mentors.
Nature’s child Just prior to 1800, a 12-year-old feral child was discovered in a forest
in Aveyron, France that would put the nature/nurture debate to the test. A medical
student, Jean Itard, took the wild boy of Aveyron into his home and devoted years to
an attempt to civilize the boy whom he named Victor. However, after many years of
instruction, Victor made minimal progress in improving his language and social skills.
Victor’s late discovery and subsequent failure to acquire language not only stressed
the importance of nurture (early environment) on development, but also suggested
the existence of critical or sensitive periods for the acquisition of certain skill sets.
Feral children today
Dramatic evidence of the importance of nurture continues to come forth in the
occasional reports of “feral” children (children raised in isolation or by animals)
who are discovered living in the wild or in severe isolation (cases of severe
confinement and abuse). Support for the importance of early environmental
stimulation is apparent, since the feral children often demonstrate significant
and irreversible developmental delays.
Nature and nurture: contemporary trends Today, theorists focus on the dynamic
interaction between nature and nurture. While it was once thought that the direction
of influence was primarily unilateral, from the parent to the child (parent → child),
social cognitive and social learning theorists such as Albert Bandura (1986) expanded
this notion to emphasize the bidirectional nature of the process, where the parent
influences the child but the child is also instrumental in influencing responses from
the parent (parent ←→ child). Furthermore, influences were seen to be evident in
three important contexts, including the environment (persons and situational events),
personal/cognitive factors (temperament, affect, biological factors), and behavior
(see Figure 1.1).
In Bandura’s social learning model, reciprocal determinism represents the dynamic
interchange between the person, the behavior, and the environment. This model of
triadic reciprocity encompasses an on-going process where individuals adapt and
adjust behavioral responses to changes in environmental demands by adjusting their
cognition, affect, and beliefs in responses to feedback. A scenario that follows Bandura’s model would include, for example, parents (environmental) who attempt to
improve a child’s weak social skills (personal/cognitive factor) by enrolling the child
in a social group experience to improve social behaviors (behavior), or a teacher who
provides remedial academic support (environment), for a student whose academic
self-esteem is low (personal factor) in order to improve on-task behavior and academic
Child and Adolescent Development: Normal and Atypical Variations
7
Environment
Child
Behavior
Personal/
cognitive
Figure 1.1 Reciprocal determinism.
According to Bandura’s (1986) theory of reciprocal determinism, the contexts that can influence a child’s behavior include: the environment and potential reinforcers (people, situations, physical surroundings), personal/cognitive factors (temperament, response style, cognitivedevelopmental level, which influence beliefs, expectations, and future responses), and behavior
(responses that may or may not have been reinforced in the past. It is important to note that
the arrows are bidirectional, in that a response in one area will impact responses in another and
vice versa.
success (behavior). Although Bandura’s model increased our understanding of the
reciprocal and triadic nature of influences, the model did not address how biological or maturational factors might impact this process. More recently, theorists have
focused on the transactional nature of the process (i.e., influences of change are
themselves changed in the process) and have attempted to incorporate this model into a
developmental framework (Cicchetti & Lynch, 1993).
Transactional processes in action: a case example
After careful deliberation, Jane decides to attend a university in Paris despite
the fact that the majority of her friends will remain in London and she is
not completely fluent in French. Her choice represents the starting point for
a number of experiences and changes that will be very different from what
she would have encountered had she remained in London. Furthermore, the
resulting changes (attitudes, behaviors, her manner of dress and language) will
also exert their influence on how she responds to her environment and how those
in her environment respond to her. Jane’s case is an example of the transactional
process in action.
8
Clinical and Educational Child Psychology
As will be discussed in Chapter 2, the first few years of life represent a time when the
developing brain is highly vulnerable to environmental stimulation, as new neural connections are being created, and old, under-stimulated pathways are being discarded.
Research has informed us that the quality of early stimulation, both mentally and emotionally, can have a profound and often prolonged influence on later development.
There is also evidence to suggest that early emotional trauma may cause profound
changes in one’s future ability to respond to stressful situations. For example, elevated
levels of the neurotransmitter norepinephrine and the hormone cortisol may, over
time, alter the ability of the hippocampus (the portion of the brain that regulates
stress hormones) to adapt to stressful circumstances (Bremner, 1999).
The high cost of living in an orphanage
O’Connor et al. (2000) studied severely deprived children from Romanian
orphanages who were subsequently adopted into homes in the United Kingdom. The study compared outcomes for children who were adopted in the
first six months with those that had remained in the orphanage for up to two
years. Results indicated that although all the children demonstrated significant
improvement, those who had been at the orphanage longest (for two years’
duration) continued to experience significant cognitive impairment four to six
years post adoption.
In a discussion of the impact of environmental and biological influences on development, Bronfenbrenner (2001) discusses the results of a study conducted in the
Dutch city of Nijmegen, by a developmental psychologist (Riksen-Walraven, as cited
in Bronfenbrenner, 2001). In this study involving 100 nine-month-old infants, parents were given a “Workbook for Parents” designed to reflect one of three conditions:
a stimulation group, a responsiveness group, and a combined group. In the stimulation group, parents were advised that stimulation was the key to positive growth
and their workbook contained a number of activities for parents to direct and promote engaged learning. Parents in the responsiveness group were instructed, much
as Rousseau would have advised, to let the children “blossom” on their own, not to
interfere or direct, but to provide opportunities for self-discovery. Workbooks for the
third group of parents contained a mix of the two approaches.
Results revealed that children in the responsiveness group demonstrated the most
significant gains on tasks of exploration and learning, followed next by the stimulation
group, and lastly, the combined group. Furthermore, long-term follow-up, at 7, 10,
and 12 years of age, revealed lasting effects for the responsiveness group, with teachers
rating these children as more “competent and skillful” than peers in the other two
groups; however, this was true only for the girls, and not the boys. The authors
reasoned that during the course of the experiment (which took place in the late 1970s
and 1980s), parents’ beliefs in the need for responsiveness strengthened their parenting
practices by allowing females far more independence and exploration than would have
taken place originally. The experiment was a testimony to the powerful effects that
can occur in interactions between biology and the environment. In Chapter 2, the
Child and Adolescent Development: Normal and Atypical Variations
9
focus will be on the nature of theoretical models and how these different perspectives
contribute to our understanding of child and adolescent development from a variety of
different perspectives: biological, cognitive behavioral, psychodynamic, and parenting
practices and family dynamics.
Milestones and periods of development
Milestones in development represent benchmarks for developmental change. Based
on the assumption that development proceeds through a predictable set of skills that
are acquired, on average, at certain age levels, it is possible to chart an individual
child’s progress relative to “normal” peer development in several areas, including:
social, emotional, cognitive, and behavioral expectations.
Periods of development and expectations for change
Investigators have charted the course of normal development, highlighting milestones
(benchmarks) that are predicted to occur within a given range of age-related expectations. Given a child’s age and stage of development, it is possible to compare a
child’s progress relative to normal expectations concerning physical, cognitive, behavioral, emotional, and social development. The actual age ranges included in each stage
of development can be arbitrary; however, most sources divide child and adolescent
development into five stages:
r
r
r
r
r
infant (0–12 months);
toddler (12–30 months);
early childhood or preschool-age (21/2–5 years);
middle childhood or school-age (6–10/11 years);
adolescence (11/12–19 years).
The topic of developmental milestones will be addressed at greater length in Chapter 3
(which addresses milestones in early childhood and school-age children) and again in
Chapter 4 (adolescence).
Risk and protective factors
We know that there are several factors that can place children and youth at increased
risk for difficulties, behavior problems, and school failure, such as: low birth weight,
having a difficult temperament, living in an impoverished neighborhood, attending poor quality schools, adverse family conditions, and negative peer influences
(Bates, Pettit, Dodge, & Ridge, 1998; Breslau, Paneth, & Lucia, 2004). However,
we also know that there are protective factors that can help buffer an individual from
harm, such as: above average intelligence, supportive parents, and social competence
(Williams, Anderson, McGee, & Silva, 1990).
In our opening case study, was Pat a boy or girl? If you said that Pat was a boy,
you have just placed Pat at increased risk for having a mental health problem, since
being male is a risk factor (Rutter, 1989). However, the fact that Pat is involved in
sports, and can share activities with peers, provides a protective buffer (Bearman &
Moody, 2004). If, on the other hand, Pat is a girl, then she would be at increased risk
for developing an eating disorder, depression, and suicidal ideation, since girls who
10
Clinical and Educational Child Psychology
feel isolated and friendless have twice the risk of suicide than their peers (Bearman &
Moody, 2004). Throughout the text, risks and protective factors will be discussed, as
they relate to the problems and challenges that children and youth face.
Determining the nature and severity of problems
The severity of a given problem or behavior can be evaluated by determining: the
frequency of the behavior (e.g., Does the behavior occur on a daily, weekly basis?);
the duration of the behavior (Is the behavior recent versus on-going?); and whether
the behavior is pervasive across situations (Is the behavior evident at home, school, or
on the playground?). Finding answers to these questions will provide an increased
understanding of whether the problem represents an adjustment reaction or is a
chronic response of a more serious and persistent nature.
Adjustment disorders are a temporary response to a known stressor, such as a relocation (e.g., a change of school). Most individuals with adjustment disorders recover
within a relatively short period of time (six months), once they have developed the
necessary skills to cope with the change. However, for some, the stress caused by
the changes may be overwhelming and mark the beginning of a more serious and
progressive decline in mental health. In this book, common stressors are identified
in a number of different contexts, such as school (transitions), at home (parental or
sibling conflict), or peer relationships. These stressful life events can place preschool
and primary school-age children and adolescents at increased risk for more serious
problems, if they are unable to develop successful strategies to cope with the stressors
(Chapter 6). In adolescence, peer pressures are discussed that can place some youth at
increased risk for opting out of a more traditional role, choosing a path that leads to
identity formation as part of a street gang.
In the opening case study, readers were introduced to Pat. However, in the initial
case presentation, there was little information given about Pat’s age, gender, and
family circumstances. Consider the additional information about Pat given in the box.
Case study of Pat: additional information
Pat is a 12-year-old male who lives with his mother who is a single parent. They
live in an impoverished neighborhood, and his mother works long hours to make
enough money to support them. Pat has no siblings, rarely sees his father, and
has been struggling academically for the past two years. With all the physical
and emotional changes taking place with the onset of puberty, Pat is having
increased problems with regulating his emotions and is becoming increasingly
moody. An increase in his academic workload has only added to his problems.
What is the next step? Given the severity of the problem, Pat’s mother would be well
advised to contact the school psychologist or a private clinician to pinpoint the nature
of the problem and determine how significantly Pat’s problems deviate from the norm.
In addition to interviewing Pat’s teachers and parent, there are a number of different
assessment instruments available, including: psychometric assessment of intelligence,
learning, cognitive, personality, and neuropsychological functioning; behavioral rating
scales, projective tests, and tests of academic performance. The psychologist may
Child and Adolescent Development: Normal and Atypical Variations
11
also want to observe Pat and conduct a functional behavioral assessment to identify
problem behaviors and the context in which they are occurring.
Results from the comprehensive psychological assessment reveal that Pat has a
number of difficulties that are contributing to his problems. Pat has problems with
inattention, concentration, sustaining attention for effortful tasks, disorganization,
ease of distractibility, and follow-through to task completion. There are also mood
fluctuations that range from irritability to giddy behaviors, evidence of grandiose
beliefs, incessant talking, and racing thoughts. Socially, Pat feels isolated at school,
although he is grateful that he can hang with his soccer buddies after the games.
Although Pat does not admit to suicidal ideation, scores on the depression inventory
are a cause for concern. Academically, Pat is scoring approximately two grades below
level, despite intelligence in the high average range.
Diagnosis and classification
What is the benefit of a diagnosis?
At this point, we have confirmed that Pat has a number of significant problems.
However, the specific nature of the problems, what is causing the problems (etiology),
and how the problems can best be treated are not self-evident. As you read this book,
the importance of a correct diagnosis will become increasingly apparent. Once a
diagnosis is made, then an entire body of pre-existing knowledge becomes available to
inform professionals about the nature and typical course of the disorder and the best
empirically supported treatments available, clinically, or the best intervention plans
that can be executed within the school setting.
Diagnosis from a clinical perspective There are two major systems of clinical classification for diagnostic purposes: the Diagnostic and Statistical Manual of Mental
Disorders (DSM), published by the American Psychiatric Association (APA, 2000)
and the International Classification of Diseases (ICD), published by the World Health
Organization (WHO, 1992). The classification systems provide a list of symptoms
and conditions that must be met in order to be given a specific diagnosis. These two
systems are categorical systems (an either/or system or binary system) that the practitioner uses to decide whether conditions are met (does the client meet the criteria?)
to warrant a diagnosis. While the DSM is used primarily in North America, the ICD
is used widely throughout Europe.
Another method of classification that is not categorical and may be more conducive
to describing child and adolescent problems is the dimensional classification system,
which conceptualizes behavior along a continuum of severity. Information about
behavior is obtained by having parents and teachers complete behavioral rating scales
to indicate the extent to which a given behavior (e.g., playing alone) is evident (never,
seldom, often, always). Once scored, these scales often generate a behavioral profile
which compares the child’s scores for each of the behavioral categories assessed (e.g.,
anxious/depressed; attention problems; social problems) with what is expected, given
the child’s age and gender. More information about each of the classification systems
is available in Chapter 5.
Diagnosis from an educational perspective From an educational perspective, Pat’s
progress could be monitored and an observational assessment carried out to
12
Clinical and Educational Child Psychology
determine the factors within the classroom environment that exacerbate the difficulty
he is experiencing. There may be a number of classroom- and curriculum-related
factors that can be adapted to alleviate some of the pressure on Pat. Factors such as
length of tasks, expectations, pace of work, type of lessons, and range of lessons can
all be adjusted to accommodate his difficulties. In addition, there are many curriculum changes and methods of lesson delivery that can be altered to assist Pat with his
learning problems and make his school experience more successful.
Diagnosis and mental health Pat’s symptoms possibly match criteria for a number of
different disorders, primarily: attention deficit hyperactivity disorder (ADHD) (as it
is called in the DSM) or hyperkinetic disorder of childhood (HDK) (as it is called in
the ICD), bipolar disorder (BD), or depression. However, prescribing medication for
ADHD/HDK could escalate symptoms of BD, causing violent aggressive outbursts,
so it is very important to establish a differential diagnosis. In this case, family history
could provide valuable information, since heritability is high in BD. Research has
shown that if one parent is diagnosed with BD, there can be a 30–35% risk to the
child of having the disorder (Chang, Steiner, & Ketter, 2000). According to Pat’s
mother, Pat’s father was diagnosed with BD in his early twenties and the reason
that their marriage broke up was due to his wild mood swings and his refusal to
take medication to treat the disorder. Given the history of BD in the family, Pat is
at increased risk for BD, a disorder that has alternating episodes of depression and
mania. Tests of cognitive function also suggest a learning disability which explains
why he has so much difficulty with written expression. Pat also demonstrates another
common challenge in working with children and adolescents, which is the tendency
for this population to exhibit comorbidity (more than one disorder concurrently).
One of the limitations of the current versions of the ICD and DSM classification
systems is that they have relatively few diagnoses that are specifically for children, and
while children may have some symptoms similar to adults, symptoms often can change
relative to the child’s developmental level. For example, generalized anxiety disorder
(GAD) is a disorder characterized by high levels of worry that is “free floating,”
not attached to any specific cause, and unreasonable. However, while a child might
be worried about not doing well at school, or not being liked by friends, an adult
might worry that they may become ill, or get into a traffic accident. Depression is
another example of how disorders may manifest differently in adults and children.
While depression can often be evident in symptoms of sadness, self-blame, and fatigue
in adults, it is often expressed as irritability in children.
Because of the emphasis on development in this book, the various disorders are
presented and described as they would appear during different developmental levels
and, rather than adhering to verbatim accounts of criteria from the DSM and ICD,
characteristics will be described as they relate to how these problems manifest at
different age levels. At the end of this chapter, readers can find an outline of the goals
of the book and the presentation format.
Theoretical frameworks: questions of etiology and intervention
An investigation of developmental issues and concerns would not be complete without
providing a foundation from which to examine how and why behaviors potentially
develop and the nature of their deviation from the normal trajectory. With this goal
Child and Adolescent Development: Normal and Atypical Variations
13
in mind, Chapter 2 provides an overview of the various theoretical frameworks that
are available to increase our understanding of how and why a problem may have
developed.
Returning to our case study of Pat as an example, let us imagine that Pat visits a
number of therapists from different theoretical backgrounds who suggest different
viewpoints as to the possible cause of and potential treatment for Pat’s “depressive
symptoms.” A therapist from a biological/neurological perspective would likely view
Pat’s depressive symptoms as an indication of low levels of the neurotransmitter serotonin, and genetic vulnerability (Pat’s father was diagnosed with BD). Treatment for
BD would most likely involve medical management to restore levels to normal; in this
case lithium, a mood stabilizer, might be prescribed. From a behavioral perspective, the
therapist may surmise that Pat’s depressive symptoms are being reinforced (rewarded)
because every time there is a complaint or default on Pat’s part, someone comes to
the rescue. Or there is also the possibility that Pat may have learned the behavior by
modeling or observing Pat’s mother’s low level of emotional responsiveness. (Pat’s
mother was recently also diagnosed with depression, which has been on-going, and
undiagnosed, for years.) Developing a contingency plan for rewarding independent
and positive behaviors would likely play a key role in the treatment program. A therapist from a cognitive perspective would evaluate maladaptive thinking patterns and
may suggest that Pat has developed a negative thinking loop (negative triad) which is
exaggerating the negative and minimizing the positive events in life. Treatment would
involve reframing thought patterns to match more positive thinking models. Finally,
a psychodynamic therapist might look at past history and discover that Pat has felt
emotionally abandoned and has feelings of insecure attachment that influence Pat’s
ability to relate to others. Long-term psychodynamic therapy may be recommended,
or if Pat were younger, play therapy might be a good alternative.
From the school perspective there are a number of initiatives that can be developed
to assist Pat in becoming more successful in the classroom. Pat’s lack of organizational
skills may be a significant roadblock to completing written assignments as Pat seems
to spend more time generating random thoughts than putting information down on
paper in a logical and predictable sequence. Potential problems with learning, attention, and executive functions will be discussed in Chapter 8, along with suggestions
for interventions and accommodations for these problems at home and at school.
A transactional ecological bio-psycho-social framework
The contribution that different theoretical models can add to our understanding
of child problems is further enhanced when supported by Bronfenbrenner’s (1979,
1989) ecological framework. More recently, Bronfenbrenner referred to his model
as a bioecological model to emphasize the biological characteristics as fundamental
to the dynamic interplay between the child and the environment (Bronfenbrenner &
Morris, 1998). This framework assists in emphasizing the interaction between child
characteristics (genetics, temperament) and environmental characteristics (immediate
and more distal influences), in an on-going and transactional nature, such that
changes beget changes and that influence is bidirectional in nature. Within this
model, the child is in the center of a number of concentric circles that represent
influences in the environment: the first wave is the microsystem that includes the
immediate surroundings, including family, school, neighborhood, and peers; the next
wave is the exosystem (extended family, economic conditions); and the final level of
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Clinical and Educational Child Psychology
influence is the macrosystem (culture, laws). All of these factors influence and are in
turn influenced by the child’s individual characteristics (biological make-up, genetic
vulnerabilities, intelligence). Interactions between the child and his or her environment
ultimately will shape the nature and direction of the child’s developmental trajectory
as the child acquires the necessary skills for successful adaptation and communication.
It is with a growing understanding of the on-going and transactional nature of the
process that we have come to appreciate how changes within the child can result in
transformations in the environment at all levels depicted above, and that, conversely,
changes at all levels of influence can impact the growing individual child, for better or
for worse. It is within this over-arching framework that development is presented and
discussed as it unfolds in its normal and atypical variations.
Risks, protective factors, and the role of chaotic environments
There has been increased interest in the influence of chaos on human development,
especially with respect to the impact of chaotic environments on children’s lives. Bronfenbrenner (2001) discusses the rise in “developmental disarray” evident in the lives
of children, adolescents, and families which he says permeates the primary life settings
from peer groups, to schools, to health care systems. Wachs and Evans (2010) suggest
an interesting framework for discussing chaotic environments, drawing upon Joachim
Wohlwill’s (1970) concept of environment stimulation and Urie Bronfenbrenner’s
bioecological model. Within this framework, the authors discuss a curvilinear model
that addresses potential negative outcomes for over- and under-stimulation, within the
contexts of Bronfenbrenner’s model of proximal and more distal influences. Some of
the environmental aspects influenced by chaos include: scarcity of resources at home
or at school, lack of family routines, harsh parenting practices, instability in child care,
noise levels in classrooms, and visually chaotic classrooms (Evans & Wachs, 2010).
Throughout this book, the concept of chaos will be addressed, as it informs developmental influences in the broader vision of factors influencing development beyond
that of a low socio-economic status environment.
Developmental deviations: clinical and educational perspectives
The role of clinical child psychologists and educational psychologists
As will become increasingly clear, clinical child psychologists and educational/school
psychologists perform many of the same functions and use many of the same assessment techniques. However, differences may be evident in the specific language that
these professions use (clinical versus educational terminology), the settings in which
they work (hospitals, schools, mental health clinics), and the focus of their practice.
Clinical child psychologists The goal of the clinical child psychologist is to address
the mental health needs of children and adolescents by reducing psychological distress
and restoring psychological well-being. Clinical psychologists can be found as part of
a multidisciplinary team, working alongside medical practitioners, social workers, and
other health professionals, or they can work independently. Common areas of practice include the treatment of psychological disorders such as depression and anxiety,
learning disabilities, or serious pathology, such as schizophrenia. The clinical child
Child and Adolescent Development: Normal and Atypical Variations
15
psychologist may work with the child or adolescent, individually or in a group, or
within the context of the family (parents, caregivers). In the United Kingdom, clinical
psychologists are most likely to be found “working in health and social care settings
including hospitals, health centres, community mental health teams” (British Psychological Society (BPS); http://www.bps.org.uk/careers-education-training/howbecome-psychologist/types-psychologists/becoming-educational-psycholo). In the
United States, clinical child psychologists can also be found in similar settings (mental health clinics, residential treatment centers, and hospitals, and working within
the juvenile justice or child welfare systems), although many clinicians work in private practice. More often than not, clinical psychologists will have a particular area
of expertise, such as providing services to child and adolescent populations, rather
than adult populations, or in specialized areas of practice, such as marital therapy,
addictions, and eating disorders. They may provide on-going therapy to assist with
transitions and emotional difficulties, and monitor progress through family contact.
Some clinical psychologists teach, and/or are involved in research to investigate the
etiology, course, and treatment of psychological disorders.
Historically, clinical child psychology as a discipline gained status in the mid-1980s
when Sroufe and Rutter (1984) launched their journal Development and Psychopathology, giving the area of developmental psychopathology the unique recognition it
deserved and setting it apart from adult clinical psychology.
Educational/school psychologists According to the BPS, “educational psychologists
tackle the problems encountered by young people in education, which may involve
learning difficulties and social or emotional problems” (www.BPS.org.uk). In the
United States and Canada, the term school psychologist is used to refer to someone in this profession, and in spite of the difference in titles, the roles are quite
similar in Canada, the United States, Western Europe, Australia, and New Zealand.
Although educational psychologists also involve parents in gathering information and
generally planning for the child, the primary context of intervention is within the
school setting, primarily involving the child and his or her teachers, or related professionals (speech and language therapists, physical therapists, school counselors).
The educational psychologist’s concerns primarily relate to the child’s learning needs
and the child’s ability to profit from his or her educational experiences, and to
enable “teachers to become more aware of the social factors affecting teaching and
learning” (BPS, http://www.bps.org.uk/careers-education-training/how-becomepsychologist/types-psychologists/becoming-educational-psycholo).
Although within the United States the majority of school psychologists are primarily
employed within the public school system, some may be employed in a liaison capacity
with the public school system, in their employment within private practice, private
schools, mental health facilities, learning centers, or hospitals. According to the BPS,
the primary employer of educational psychologists in the United Kingdom is also the
local education authorities, and as such educational psychologists are most likely to
be found in “schools, colleges, nurseries and special units” and to “liaise with other
professionals in education, health and social services.” However, the BPS notes that
there are growing numbers of educational psychologists who can be found working
independently or as private consultants.
Historically, educational psychologists and school psychologists have faced similar
challenges due to the enactment of educational policy in their respective locations.
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Clinical and Educational Child Psychology
The Education Acts of 1981 and 1993 in the United Kingdom placed emphasis
on the identification of children with “special educational needs” (SEN) and clearly
prioritized assessment as the primary function of educational psychologists (Fallon,
Woods, & Rooney, 2010; Woods, 1994). In the United States, a similar movement
was launched with the passing of the Education for All Handicapped Children Act
(EHA, 1975) and its reauthorization as the Individuals with Disabilities Education Act
(IDEA, 1990) which relegated school psychologists to a position as “gate keepers”
to special education placements in their assessments to determine placements and ongoing meetings to review placements (Dahl, Hoff, Peacock, & Ervin, 2011; Reschly &
Ysseldyke, 1995). There is an increasing trend among these professionals, globally, to
become more involved in research initiatives, providing input into educational policy,
and to become more engaged in practices of training and professional development
(Fallon, Woods, & Rooney, 2010; Nastasi & Varjas, 2011).
The intersection of clinical and educational psychology
In her article addressing critical issues children will face in the twenty-first century,
Crockett (2004) lists issues including: poverty, violence, bullying and harassment,
teen pregnancy/sexual behavior, alcohol and drug abuse, mental health issues and
services, diversity and tolerance, and access to quality education and technology.
Although this list of issues is based on statistics gathered concerning children in the
United States, there is no question that these matters are of global concern in their
overall impact on child development and well-being. Additionally, Crockett notes
that although these issues represent challenges to all children, responding to these
issues is even more challenging for children who experience these difficulties in conjunction with academic, behavioral, and emotional problems. Within this context,
shifting roles and priorities, globally, have had an impact on professionals whose
main goal is to work with children and adolescents facing these challenges with an
increasing need to enhance their skills in all areas (professional training and collaboration). For example, in England, the training of educational psychologists “has
moved from a one year Masters to a three year Doctoral programme” (Norwich,
Richards, & Nash, 2010), while in the United States, greater numbers of school
psychologists at the Master’s level are returning to graduate school to upgrade to a
Specialist or Doctoral level. Within the last 10 years, several universities in the United
States have developed combined Doctoral programs that integrate clinical and school
psychology.
Furthermore, policies such as Every Child Matters (DfES, 2004) in Europe and
No Child Left Behind (US Department of Education, 2001) in the United States
have impacted the further expansion of the role of educational psychologists into
areas of consultation and intervention, further blurring the lines between these two
“psychologies.”
Clinical and educational psychology: international focus on psychology
in the schools
According to the WHO (2005), between 5% and 20% of children and adolescents
are in need of mental health services, globally. In their attempt to track and identify
Child and Adolescent Development: Normal and Atypical Variations
17
the mental health needs of children and adolescents, the WHO cites a number of
difficulties encountered, including the fact that:
Child mental health needs are often inter-sectoral or present in systems other than the
health or mental health arena. Children with mental health problems are often first seen
and first treated in the education, social service or juvenile justice systems. Since a great
many problems of youth are identified in the education sector, these problems may or
may not get recorded as mental health problems or needs.
(WHO, 2005, p. 7)
In addition, shortage of services is a major roadblock to obtaining appropriate care for
mental health issues for children and adolescents, with access rates ranging between
20% and 80%, globally. Scandinavian regions of Europe have the highest access rates,
while those countries that have higher proportions of children have the least available
services. In order to address growing concerns regarding availability of and access
to mental health services for children and adolescents worldwide, the International
School Psychology Association (ISPA) distributed a survey to 43 different countries to evaluate the roles, responsibilities, professional preparation, and challenges
of school psychologists. The survey revealed that although these individuals shared
common professional duties, such as individual assessment (of cognitive, social, emotional, and behavioral difficulties), development of intervention plans, and consultation,
there was wide variation in their professional titles (school/educational psychologist,
counselor, psychologist in schools/education, psychopedagogue) and the location
where they delivered their services. While some professionals were located in the
schools, others could be found in clinics, hospitals, and universities (Nastasi & Varjas,
2011). The survey revealed that school psychology services were best developed in the
United States, Canada, Western Europe, Israel, Australia, and New Zealand (Jimerson,
Oakland, & Farrell, 2007). In their chapter on international implications for school
psychology, Nastasi and Varjas (2011, p. 815) emphasize the need to open the doors
to more program focus on cultural and global concerns and the infusion of “culturally
and contextually relevant (e.g., culturally constructed) programs, promotion of sustainability and institutionalizing, translation to other contexts and dissemination to
facilitate international development of school psychology.” In the spirit of addressing
this need, this book provides an international focus on research, as well as emphasis on global concerns that will assist practitioners in their work with children and
adolescents in clinical and educational settings across the world.
Goals and organizational format of this book
The goal of this book is to provide a comprehensive look at typical developmental
patterns in childhood and adolescence (two to 18 years of age) and discuss how common challenges encountered during these key periods of development (stressors at
home, at school, and in the environment) can influence the developmental trajectory
for better or worse, depending on the child’s ability to cope and master these challenges. The book will explain why children who encounter multiple stressors may not
be successful in developing adequate abilities to control their emotions or regulate
their behaviors relative to age-based expectations, and how these children, without
18
Clinical and Educational Child Psychology
important and necessary interventions, may become vulnerable to a host of clinical,
educational, and mental health problems. The book is divided into two major parts:
Part One: The foundations;
Part Two: Child and adolescent problems and disorders.
Each part addresses key issues relevant to a better understanding of the extent and
nature of child and adolescent problems.
Part One: The foundations
This introductory section consists of five chapters and provides the necessary theoretical background to assist readers in better understanding how children and adolescents
develop their perceptions of their world, their feelings about themselves and others,
and their responses to these perceptions and feelings.
In Chapter 2, readers are introduced to five theoretical models, including: the biological model (brain chemistry, anatomy, and function), the cognitive behavioral model
(the development of thoughts about ourselves and others and how behaviors are
learned), the psychodynamic model (unconscious motives and defenses, as well as issues
in attachment), and models of parenting practices and family dynamics (parenting style
and family systems theory). Ultimately, the chapter presents an over-arching framework, a transactional, ecological bio-psycho-social framework that integrates information
from all the theoretical models and encompasses the total child.
In Chapter 3 and Chapter 4, normal developmental milestones are discussed, to
provide readers with the necessary benchmarks for development in early and middle
childhood (Chapter 3) and adolescence (Chapter 4), as these changes relate to physical,
neurological, cognitive, emotional, and social development. A thorough understanding of the expectations for development in these areas provides the foundation for
evaluating the extent of deviation from the norm in later discussions of disordered
behaviors. Each of these chapters concludes by presenting the latest contemporary
research on the influences of attachment and parenting styles on child and adolescent
development.
Chapter 5, the final chapter of Part One, provides an overview of the many ethical
issues that are involved in working with children and adolescents, in research and
clinical practice. The chapter provides clinical and educational perspectives on the
nature of developmental deviations and how these may be assessed and evaluated.
Discussion concerning issues of diagnosis and classification looks at some challenges in
applying current systems to child and adolescent problems. Ethical issues and concerns
facing practitioners working with children and adolescence are discussed as they relate
to practice and research, internationally. Finally, international concerns of clinical and
educational/school psychologists are discussed as they relate to contemporary child
and adolescent issues and current challenges to practice.
Part Two: Child and adolescent problems and disorders
The first chapter of Part Two, Chapter 6, is devoted to adjustment problems that children and adolescents can face on a daily basis resulting from stressors in their school,
family, and social environment. The discussion of adjustment problems is strategically
placed at the beginning of the section because these are common stressors which can
interfere with positive developmental outcomes on a temporary basis, but can evolve
Child and Adolescent Development: Normal and Atypical Variations
19
into more significant disorders if not recognized and addressed appropriately. In this
way, these problems can be seen as a bridge between normal and disordered behaviors.
Sequencing of disorder presentation Recent efforts to revise the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases
(ICD) have prompted discussions regarding how best to cluster or group disorders
based on information available from recent research. With respect to the reclassification of childhood disorders, Andrews, Pine, Hobbs, Anderson, and Sutherland (2009)
conducted a meta-analysis of childhood disorders that currently appear in the DSM
(APA, 2000) in the category of “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” and the ICD categories of “Mental Retardation,” “Disorders
of Psychological Development,” and “Behavioral and Emotional Disorders with Onset
Usually Occurring in Childhood and Adolescence.” As part of their review, Andrews
et al. (2009) considered the validity of including different childhood disorders under
the umbrella of neurodevelopmental disorders, including: conduct disorder (CD),
separation anxiety disorder, attention deficit hyperactivity disorder (ADHD), mental
retardation (intellectual disability), pervasive developmental disorders (autistic spectrum disorders), motor disorders, communication disorders, and learning disorders.
However, while some disorders seemed to match a number of validating criteria, such
as intellectual disability and pervasive developmental disorders, others, such as subtypes of ADHD, shared some features with neurodevelopmental and externalizing
disorders, such as CD. Ultimately, Andrews et al. (2009) suggest the possibility of
five disorders being clustered within the category of neurodevelopmental disorders,
based on genetic etiology, symptom similarity, cognitive impairment, early onset, and
persistence of course. The five disorders suggested are: mental retardation (intellectual disability), pervasive developmental disorders (autism spectrum disorders), motor
disorders, communication disorders, and learning disorders.
For purposes of this book, Chapter 7 includes three primary neurodevelopmental
disorders (intellectual disability, autistic spectrum disorders, and communication disorders), as well as other disorders with early childhood onset (feeding disorders and
selective mutism).
In Chapter 8, students are introduced to disorders that involve problems of learning (five types of specific learning disabilities) and attention disorders with or without
hyperactivity and impulsivity and how these disorders impact academic performance,
as well as social-emotional functioning. From a developmental perspective, these problems are most likely identified within the first two to three years of formal schooling.
The chapter provides important information on etiology, identification, and intervention for these disorders.
In Chapter 9, the discussion evolves around a wide range of externalizing behaviors
which are often the most frequent source of referrals for mental health services. A
continuum of behavioral problems are introduced, ranging from mild forms of early
aggression to bullying and victimization of peers, behaviors that challenge authority
(oppositional defiant disorder), and behaviors that violate the rights of others (conduct
disorder). The chapter also addresses recent emphasis on the callous and unemotional
specifier for conduct disorder, and how the disorders are assessed and treated.
Internalizing disorders are the focus of Chapter 10. In this chapter, some of the most
frequent disorders are discussed, including: anxiety disorders (phobias, separation
anxiety disorder, generalized anxiety disorder, obsessive compulsive disorder, and
panic disorder), mood disorders (major depression, dysthymia, and bipolar disorders),
20
Clinical and Educational Child Psychology
and somatization disorders and somatic concerns. The chapter addresses how these
disorders manifest in children at different levels of development, as well as discussing
assessment and treatment alternatives. Suicide, which increases greatly in adolescence,
is also discussed in this chapter, as well as a very successful school-based suicide
prevention program that is available.
There has been growing international concern about the increase in eating disorders
and substance use and abuse among children and youth. In Chapter 11, these concerns
are addressed by discussing the results of numerous surveys that have been conducted
internationally to draw attention to the decreasing ages and increasing prevalence rates
for eating disorders and substance use and abuse. Empirically supported treatment
alternatives and prevention programs are presented.
In Chapter 12, the topic of child maltreatment is addressed from an international
perspective, as it relates to physical, sexual, and emotional maltreatment, as well as
child neglect and situations of multiple maltreatment. Self-injurious behaviors are also
addressed in this chapter, because they are often triggered by perceived maltreatment.
This chapter is strategically placed prior to discussions of child trauma and trauma
disorders, since many children who are maltreated also develop post-traumatic stress
disorder (PTSD).
Finally, in Chapter 13, the discussion will focus on child trauma and trauma-related
disorders. Reactive attachment disorder and acute and post-traumatic stress disorder (PTSD) will be addressed, as well as how symptoms of these disorders manifest
across the developmental spectrum. Discussion will focus on concerns regarding the
identification of PTSD in preschool children.
Format of the presentation of the clinical disorders Each of the chapters will be
presented in a consistent format which includes a diagnostic description of the
disorder, followed by a discussion of the nature and course of the disorder, etiology
and prevalence rates, and assessment and treatment alternatives. The following is an
overview of the types of information that will be presented in each of the sections
outlined, as follows.
Nature and course This section will provide a description of the disorder/problem.
The intention is not to provide a verbatim account of diagnostic criteria as they appear
in the DSM or ICD, since readers can access these manuals directly. What will be
provided is general information about the disorder, such as symptoms and subtypes,
as well as differential diagnostic considerations, and any disparities in how the disorders
are conceptualized by the different classification systems.
The section will also provide a description of developmental characteristics, chart
the course of the disorder, and present findings from research concerning how the
disorder manifests across the different developmental levels.
Etiology and prevalence Etiology will be discussed in relation to various theoretical frameworks (biological, cognitive-behavioral, psychodynamic (attachment) and
parenting styles), and prevalence rates will be provided as they relate to current research
in the field.
Assessment and treatment There are many assessment instruments and checklists
that can be used to provide general information about a child’s personality, selfesteem, and behavioral profile. Depending on his or her age, questionnaires can be
Child and Adolescent Development: Normal and Atypical Variations
21
completed by the child/adolescent, or by an adult familiar with the child (parents, caregivers, teachers). In Chapter 5, many general assessment instruments are introduced
as they relate to the evaluation of cognitive, academic, and psychological/behavioral
functioning. This section will very briefly draw attention to symptom-specific instruments that are available to compare a child’s or adolescent’s level of responses in a
particular area (e.g., anxiety, depression) relative to others in the same age range,
and will serve to orient readers to other sources for more in-depth information on
the instrument.
The importance of identifying empirically supported treatments has gained increasing emphasis, developmentally. The focus will be on providing developmentally appropriate methods of intervention that represent a wide variety of theoretical frameworks
(cognitive-behavioral, family systems, play therapy, biomedical management, special
education) and systems of delivery (individual, group, and family therapy).
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2
Theoretical Models
Chapter preview and learning objectives
Theoretical models: an introduction
The biological model: physical and neurological development
Neurological development
Genetics and heritability
Bio-physiological responses to stress and threat
Summation: the biological model
Cognitive and behavioral models
Behavioral models
Classical conditioning
Operant conditioning
Modeling or observational learning
Cognitive models
Cognitive neuroscience and executive functions
Social cognitive models
Cognitive behavioral therapy (CBT)
Psychodynamic models and attachment
Freud and the Neo-Freudians
Attachment theory and models of attachment
Parenting practices and family dynamics
Parenting style
Family systems theory
The total child: an over-arching framework
A transactional ecological bio-psycho-social framework
Bronfenbrenner and the contexts of development
References
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Chapter preview and learning objectives
Developmental changes can be shaped by a variety of contextual influences (heredity
and environment) and interpreted from a number of theoretical perspectives. Within
this chapter, the nature of developmental change will be viewed from the vantage point
of five important theoretical models: the biological model, the cognitive and behavioral
models, the psychodynamic model (attachment), and the parenting practices and
Clinical and Educational Child Psychology, First Edition. Linda Wilmshurst.
© 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.
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Clinical and Educational Child Psychology
family systems model (including theories of parenting style and practices). Ultimately,
a transactional ecological bio-psycho-social model will be discussed as the over-arching
framework. Information presented in this chapter will provide readers with a better
understanding of:
r
r
r
r
r
r
r
how different models contribute to our knowledge of developmental change;
the role of contextual influences in shaping the course of development;
important neurological and physiological changes that occur in childhood;
behavior as a learned response;
the role of cognition in maladaptive thinking;
the role of parenting practices and attachment styles in outcomes for child development;
the importance of theoretical models in guiding the development of intervention
programs.
Although the child was once seen as a passive recipient of information, we now know
that interactions between the child, the caregiver, and other environmental factors
are not only bidirectional but represent a complex, dynamic, and on-going process.
These influences can alter the trajectory for growth, for better or worse, and shape the
course of future development. Contemporary theorists emphasize the transactional
nature of the developmental process as it unfolds in an environment that may place the
child at increased risk or provide him or her with increased opportunities for growth.
The transactional process will be discussed in greater detail later in this chapter.
Theoretical models: an introduction
Theoretical models can provide a framework for organizing information, and can assist
in understanding the etiology of child and adolescent problems. The case example cited
in the text box provides an opportunity to view one disorder, in this case depression,
as it might be envisioned by therapists who represent a number of different theoretical
(psychodynamic, behavioral, cognitive, and biological) orientations.
In the eye of the beholder
Cecile is concerned about her six-year-old son Jason’s increasingly noncompliant
behavior; every request turns into a major battlefield. She seeks counsel from
four different therapists who all agree that Jason has oppositional and defiant
behaviors, but all provide different reasons and suggestions for improvement.
The psychodynamic therapist suggests that noncompliance represents an internal
and unconscious conflict which is causing anxiety and suggests that struggles
represent the conflict between Jason’s needs for dependence and autonomy
which are at the core of the problem. He recommends conjoint play therapy so
that mother and son can work through these conflicts. The behavioral therapist
states that noncompliance is being rewarded because the mother gives up after
several requests, and then completes the chores herself, and the suggestion is
Theoretical Models
25
for a program that rewards Jason’s compliance with requests. The cognitive
therapist states that Jason’s noncompliance results from maladaptive thought
processes, resulting from Jason’s belief that he cannot do anything right to
please his mother and has stopped trying as a result (learned helplessness). The
biological therapist suggests that the problems between Cecile and Jason relate
to their temperaments and that there is not a “goodness of fit” between the
two. Basically, Cecile is highly strung and a bit of a perfectionist, while her son
Jason is more prone to avoid any emotional tension. Given this mix, Cecile
pushes when Jason tries to withdraw and problems escalate into a battle of wills.
Training in relaxation exercises will help both to reduce the tension and help
them deal with the issues in a calm and reasonable manner.
It is important to recognize, however, that a model can also represent a set of
inherent biases and assumptions that can influence the nature of inquiry, the method
and target of observations (behaviors that are emphasized and those that are minimized), and the conclusions resulting from the inquiry. As a result, based on the
particular model employed, one observer may emphasize how a given behavior is
learned through environmental contingencies (according to the behavioral model),
while another observer may be more likely to evaluate the underlying thought processes and faulty reasoning that are responsible for the same behavior (according to
the cognitive model). It is evident that each model contributes a given set of assumptions about the behavior based on a unique conceptual framework that will ultimately
shape the expectations for future outcomes (social, emotional, cognitive, physical,
behavioral), and guide the course of treatment and intervention. From a biological
perspective, inherited traits might be the first line of insight into the problem areas,
while, if needed, medication might be a therapeutic option if the problem was related
to some form of chemical imbalance. From a behavioral or cognitive perspective, programs designed to change existing behaviors or reframe maladaptive thoughts might
be the most appropriate course of action.
While it is important to know the contributions that each of these perspectives adds
to the overall picture, contemporary theorists have increasingly focused their attention
on achieving a better understanding of the relationships between or among the various
models and how certain perspectives can provide building blocks and better inform us
about how the various aspects of the total child fit the bigger picture. A schematic of
the different theoretical models discussed in this book and their predominant focus is
presented in Figure 2.1.
The biological model: physical and neurological development
The biological model emphasizes the “nature” side of the heredity and environment equation, and addresses how biological, genetic, and physiological factors
contribute to human behavior. From this perspective, causes of behavioral and developmental change can be traced to abnormalities in the brain (anatomy or chemical function/malfunction) or genetics (heredity and the influence of potential genetic
risk factors). Since brain chemistry can be linked to various mood states (such as
26
Clinical and Educational Child Psychology
The total child
An over-arching
framework:
A transactional
ecological
bio-psycho-social
framework
Biological model:
Physical and
neurological
development
Influence of brain
anatomy, activity,
and genetics
Cognitive behavioral model
Cognitive model:
Behavioral model:
Thinking about the world,
ourselves, and others
Thoughts that influence
feelings and behaviors
Learning and behavior
Behaviors are learned
through classical or
operant conditioning
or modeling
Psychodynamic model:
Unconscious motives
and defenses
Attachment
Parenting practices and
family dynamics:
Parenting style
Family systems
Family environmental
influences
Figure 2.1 Theoretical models and child development.
depression and anxiety), clinicians often rely on a biological answer to explain etiology and provide direction for medical treatment to restore the appropriate chemical
balance (neurotransmitter function) and brain function.
Historical advances Initially, autopsies on humans and research with animals were
the only available methods of localizing functions such as memory and sensory receptors in the brain. Increased knowledge from technical advances, such as functional
magnetic resonance imagining (fMRI), have provided opportunities to localize activity
levels in the brain. As a result, our knowledge of abnormal brain activity in populations
with different disorders (dyslexia, attention deficit disorder, schizophrenia, and so on)
has increased substantially.
Different brain activity can signal different problems
Children with attention deficit hyperactivity disorder (ADHD) often demonstrate reduced activity in the frontal lobes, while those with dyslexia exhibit
over-stimulation of the inferior frontal gyrus (Shaywitz, 1998).
Theoretical Models
27
Axon of
nerve cell
Neurotransmitters
Synapse
Receptors
Dendrite of
nerve cell
Figure 2.2 Chemical activity in the brain: neurotransmitters send messages across the synapse.
Neurological development
Neurological development refers to brain anatomy, location of function, and chemical
responses to activation of neural impulses (neurotransmitters) and responses from the
endocrine system (corticosteroids).
Neurons and glial cells The brain and spinal cord make up the central nervous
system (CNS) which is comprised of: neurons, cells that send and receive messages;
and glial cells, cells that provide support, nutrition, insulation, and maintenance
(clean-up of dead neurons). There are three types of neurons that specialize in transmitting different types of messages: sensory neurons (which transmit messages to
the five senses); motor neurons (which transmit messages of fine and gross motor
movements), and interneurons (which are located in the cerebral cortex, and act as a
link between the sensory and motor neurons).
Growth and development of the brain’s neurons and the number of synapses
(gaps between neurons where messages are transmitted) created escalates during the
first two years of life. The neurons transmit messages to other neurons by releasing
chemicals called neurotransmitters into the synapse. The chemical responses and
synaptic activity are depicted in Figure 2.2.
Neurotransmitters Neurotransmitters are chemicals that send messages to excite or
inhibit responses. For example, GABA (gamma-aminobutyric acid) sends a message
to inhibit responses; however, when a malfunction occurs, anxiety can be the result.
Too little, or too much, of a neurotransmitter in the system can result in shifts in
moods and behaviors (e.g., low serotonin levels can result in depression).
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Clinical and Educational Child Psychology
Development and efficiency of message transfer Within the first two years of
life, the brain constructs new neural networks and enhances the efficiency of the
transmission of the neural messages, by pruning and myelination. Until middle
adolescence, periods of prolific creation of connections are followed by periods of
clever housekeeping (pruning). During this period, connections that are frequently
used will be strengthened, while the least-used connections will be eliminated. Since
formation of neural pathways is dependent on the number and variety of experiences
that a toddler is exposed to, early intervention programs are essential in increasing
opportunities for later success.
One language or two: bilingualism and the brain
Although some parents are concerned that learning two languages may have an
adverse effect on the developing brain, research has demonstrated the opposite.
Native bilingual children (Spanish-English bilingual) were found to outperform
monolinguals (English) or peers in the second-language immersion kindergarten
on tasks of cognitive flexibility, such as executive function tasks requiring the
management of conflicting attentional demands (Carlson & Meltzoff, 2008).
During the first two years of life glial cells are instrumental in regulating the production and maintenance of myelin, a fatty sheath that coats the nerve fibers. The
process of myelination increases the conductivity of neural impulses to create more
efficient message transmission.
Other chemical messengers
While neurons send excitatory or inhibitory messages by releasing chemicals into
the brain (neurotransmitters), hormones released into the bloodstream by the
endocrine system also send messages to excite or inhibit responses.
Brain anatomy and brain function Three weeks after gestation, cells begin to
differentiate into three regions that will form the hindbrain, the midbrain, and the
forebrain.
Hindbrain The hindbrain is the lowest portion of the brain, consisting of the
medulla, cerebellum, and pons. The hindbrain links the spinal cord to the brain and
regulates respiration (medulla), consciousness, arousal (pons), and the coordination
of smooth muscle movements (cerebellum). The medulla is the area where the nerves
cross over from the left side of the body to the right side of the brain and the right
side of the body to the left side of the brain.
Theoretical Models
Frontal lobe
(abstract thinking,
planning,
social skills)
29
Cerebrum
Body
Movement
Parietal
and coordination Bodily Lobe
Sensations
Frontal
Lobe
Thought and
Consciousness
Speech
Hearing
Occipital
Memory for
Lobe
Speech Reading
Memory for Sight Visual
Sight
Images
Memory for Music
Temporal lobe
(language, hearing,
visual pattern
recognition, speech)
Smell
Temporal
Lobe
Parietal lobe
(touch, taste,
nonverbal
thinking, spatial
orientation)
Pons
Occipital lobe
(vision)
Coordination
Medulla Oblongata
Cerebellum
Spinal Cord
Figure 2.3 Parts of the brain.
Midbrain The midbrain is located between the hindbrain and the forebrain and
contains the reticular activating system (RAS) which is responsible for habitual
patterns of behavior such as walking and sleeping.
Forebrain The forebrain contains structures of the highest and most complex functioning which separates humans from chimpanzees and other animals. The forebrain
contains such structures as the limbic system, which is responsible for learning,
emotion, memory, and motivation. The major parts of the brain can be seen in
Figure 2.3.
The brain and survival
The brain stem, which is the most primitive part of the brain, includes the
hindbrain (excluding the cerebellum) and the midbrain. The brain stem is
responsible for basic survival functioning, such as determining the level of alertness/consciousness and regulating breathing, heartbeat, and blood pressure
(Rollenhagen & Lubke, 2006).
The cortex and structures under the cortex The cerebral cortex (“cortex” is Latin
for “bark”) is the convoluted grey mass that covers the brain, consisting of many
tightly packed interneurons. The limbic system is located just under the cortex and
contains the thalamus, hypothalamus, hippocampus, and amygdale.
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Clinical and Educational Child Psychology
Thalamus The thalamus is the part of the forebrain that acts as a relay station for
sensory information, passing it on to the cerebral cortex from the sensory organs.
Hypothalamus In addition to regulating normal body functions, such as temperature and metabolism, the hypothalamus also regulates fear, thirst, sexual drive, and
aggression.
Hippocampus Our ability to remember and form new memories is influenced by the
hippocampus (e.g., our ability to compare our perceptions of sensory information to
our expectations). The hippocampus is also rich in the neurotransmitter acetylcholine
which is associated with memory and muscle control. Individuals with Alzheimer’s
disease register lower levels of acetylcholine in the hippocampus than normal.
Amygdale Our recall for emotional events, fear, and memory for fear are all under
the influence of the amygdale, as is our ability to interpret nonverbal emotional
expressions.
Given the specific functions of each of these brain structures, it is not surprising to
see how individuals who sustain brain injury or trauma (e.g., due to closed head injury
or stroke) can lose specific function in one area but are able to maintain functioning
in other areas that are not compromised.
There are two symmetrical cerebral hemispheres (halves) which are separated by a
deep fissure that contains a strip rich in neural fibers (corpus callosum). There are
four major areas (lobes) found in each hemisphere, responsible for specific functions:
occipital lobes (vision), parietal lobes (sense of touch, movement, and location of
objects/body in space), temporal lobes (auditory discrimination and language), and
frontal lobes (attention, planning and social skills, abstract reasoning, and memory).
The frontal lobes house the executive functions which are responsible for managing,
directing, and controlling problem-solving activity. The executive functions are discussed at length in Chapter 8. (See Figure 2.3 for a graphic illustration of where the
lobes are located.)
Genetics and heritability
Closely tied to a discussion of brain development, anatomy, and chemistry is the
concept of genetic inheritance. Our understanding of the heritability of certain characteristics has increased significantly due to studies that have focused on twins reared
together or twins reared apart (adopted into different households). Genetic transmission can be traced in monozygotic (MZ) twins, identical twins, compared to
dizygotic (DZ) twins, fraternal twins.
A study of MZ twins and DZ twins provides a comparative analysis of the influence of genetic factors, while controlling for environmental factors. It is also possible
to compare MZ twins reared together with those reared apart to evaluate the influence of environmental factors on development. As a result, recent longitudinal studies
have revealed that although environmental factors, such as child maltreatment, can
increase the risk of antisocial behavior in adulthood, negative outcomes may be moderated by genetic factors, such as an individual’s genotype (Caspi et al., 2002; Caspi
et al., 2003).
Theoretical Models
31
Twins and DNA
The difference between monozygotic (MZ) twins or identical twins and dizygotic
(DZ) twins or fraternal twins is that MZ twins develop from the same ovum
which splits after fertilization, while two different ova are fertilized for DZ twins.
As a result, MZ twins share identical DNA, while DZ twins share similarities in
DNA, comparable to that of other siblings.
Phenotypes and genotypes
Children inherit 23 chromosomes from each parent (22 autosomes and 1 sex
chromosome). Phenotype refers to those inherited characteristics which are
visible, such as eye color and curly or straight hair, while genotype refers to
inherited characteristics which are not visible (DNA code).
More recently, studies have focused on endophenotypes (phenotypical markers or
systems that are thought to underlie a given psychological disorder) such as clusters of
traits that may come together to explain the existence of certain behavioral tendencies.
Lahey, Moffitt, and Caspi (2003) found a certain cluster of endophenotypes that place
individuals at greater risk of engaging in antisocial behaviors, including: frontal lobe
hyperarousal, fearlessness, callousness, and negative emotionality.
Genes can influence how we interact with the environment,
but can environment influence genes?
Studies of infants exposed to prolonged trauma (Beers & De Bellis, 2002)
have demonstrated changes in the brain’s responses to subsequent stressors
(hyperarousal), providing support for the theory of a bidirectional influence
between heredity and environment (epigenesis) where environmental influences
can actually be responsible for changes in genetic make-up.
Temperament as a genetic trait In infancy and early development, temperament
refers to the general behavioral style that is relatively constant across situations.
Although personality traits or characteristics can be learned, there is support for the
genetic transmission of a number of traits, such as general activity level, ease of distress,
and inhibition or wariness (Kagan, 1992; Plomin, 1994; Rothbart, Ahadi, & Evans,
2000). Although infants can show a wide range of responses to their environments, by
12 months of age caregivers describe infants as having a unique individual style, with
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Clinical and Educational Child Psychology
some children being more social and approachable and others being more irritable
and emotionally reactive (DeHart, Sroufe, & Cooper, 2004).
One of the earliest research teams to investigate temperament was Thomas and
Chess (1977) who rated infants (on a scale from 1 to 10) on the relative strength of
the following nine behavioral traits: activity, intensity of response, distractibility, persistence of attention, rhythmicity (biological regulation of function, such as sleeping
and eating patterns), adaptability, sensory threshold, mood, and approach-avoidance.
Studies have suggested that difficult babies are associated with a greater number of
negative outcomes than their easy-going peers. Contemporary researchers have also
investigated the need to consider the “goodness of fit” between a parent’s style and
the child’s response style, which may be instrumental in promoting stability, or serve
to exacerbate problems. For example, Patterson, DeBaryshe, and Ramsey (1989)
found that children with “difficult temperament traits” tend to have parents who
are themselves highly reactive and punitive. However, the nature of the interaction
remains unclear and the question remains: are the parent and child responses similar
due to genetic transmission, or environmental influence, or are these similarities an
example of what Scarr and McCartney (1983) have described as “evocative” gene–
environment interactions?
Easy baby . . .
Based on the intensity and combination of characteristics, Thomas and Chess
(1977) found that 60% of infants could be classified into one of three categories: easy babies (high in rhythmicity, approach, positive mood, and adaptability), difficult babies (low in rhythmicity and adaptability, and high in avoidance, intensity, and negative moods), and slow-to-warm-up babies (mid-range
rhythmicity, mild negative reactions to new experiences, adaptive over time).
Bio-physiological responses to stress and threat
In the chapters that follow, discussions of how children respond to perceptions of
threat or stress, will focus on physical, emotional, cognitive, and behavioral responses.
When a stressful event occurs, the hypothalamus places two important systems on
alert: the autonomic nervous system (ANS) and the endocrine system. In response
to the alert, there are two pathways that mobilize responses of arousal and fear: the
sympathetic nervous system pathway and the hypothalamic–pituitary–adrenal
(HPA) pathway. The two pathways are presented graphically in Figure 2.4.
Sympathetic nervous system pathway The ANS regulates the involuntary activities
of organs, such as pupil dilation, respiration, and heart rate, through two complementary systems: the parasympathetic nervous system and the sympathetic nervous
system. When the ANS receives a message of alert from the hypothalamus, this
message is relayed to the sympathetic nervous system, and nerve impulses are sent
to the organs to inhibit or stimulate functioning. When the threat has passed, the
parasympathetic nervous system returns the system to normal (heart rate and breathing
slow down).
Theoretical Models
33
STRESSOR
HYPOTHALAMUS
Autonomic nervous system
Endocrine gland system
Sympathetic
nervous system
Alert to
fight or flight
Parasympathetic
nervous system
Return to calm
Pituitary gland
Secretes
hormones into
bloodstream
Adrenal medulla
Releases
neurotransmitters:
epinephrine (adrenaline)
and norepinephrine
(noradrenaline)
Direct activation
of organs
FEAR AND AROUSAL
FEAR AND AROUSAL
Adrenal cortex
Releases ACTH
corticosteroids
(cortisol)
FEAR AND AROUSAL
Figure 2.4 Hypothalamus relays stress alert through the sympathetic nervous system pathway
and the hypothalamic–pituitary–adrenal (HPA) pathway.
Hypothalamic–pituitary–adrenal (HPA) pathway The endocrine system controls
the endocrine glands which secrete hormones into the bloodstream. The HPA
pathway has been implicated in biological explanations for adjustment problems,
anxiety, stress disorders, and mood disorders. In response to danger or threat, the
hypothalamus activates the pituitary gland which causes the adrenal glands to release
corticosteroids, a group of stress hormones, such as cortisol, into the system in order
to mobilize vital organs to respond to the stressful situation, or pending threat.
Summation: the biological model
The biological model contributes to our understanding of child development in a
number of significant ways. First, the model provides an understanding of how neurological development should proceed developmentally, and also informs us of the
underlying brain structures associated with specific functions. Second, it increases our
34
Clinical and Educational Child Psychology
awareness of the importance of early stimulation in the formation of new neural pathways. Third, understanding the bio-physiological response pathways enhances our
awareness of the impact of stress on children at a very early age. Information gathered from twin studies has provided an increased appreciation of the role of genetics
in such disorders as dyslexia, learning disabilities, autism, bipolar disorder, anxiety,
and schizophrenia. In addition, we are becoming increasingly aware of the complex
nature of the interplay between genetics and environmental influences (e.g., that the
environment can shape the brain and vice versa). Based on evidence of the role of
early experiences in shaping our behaviors and the ability to predict adult characteristics based on childhood traits, the importance of early stimulation and intervention
becomes increasingly apparent.
Cognitive and behavioral models
Many therapists combine the use of cognitive and behavioral methods in what is
referred to as cognitive-behavioral therapy (CBT). To assist with better understanding how each of these components contributes to CBT, this discussion begins
with an in-depth look at each of the models individually.
Behavioral models
While theorists from a biological perspective look to brain function, structure, and
genetics to help explain the nature of development, theorists rely on a behavioral
model to explain how certain behavior patterns are learned. The principles of learning
will assist in predicting how behavior develops and is maintained in three important
ways:
r
r
r
classical conditioning;
operant conditioning;
modeling or observational learning.
Classical conditioning The classical conditioning paradigm is very helpful to our
understanding and treatment of irrational fears or specific phobias (sometimes called
simple phobias) which are actually quite common in children.
Pavlov and the salivating dogs
Although Ivan Pavlov has become famous for his theory of classical conditioning, his discovery of the phenomenon was really by coincidence. Pavlov was
actually studying salivation in dogs, when he made an important discovery.
Pavlov noticed that the dogs began to salivate (a reflex response) in response
to the sounds of the food being prepared before the dogs received any food.
He later introduced a bell to announce the food and the dogs quickly began to
salivate in response to the bell.
Theoretical Models
35
Table 2.1 The classical conditioning paradigm explains how little Albert was conditioned to
fear the rat
Prior to conditioning:
Stimulus
White rat
Neutral stimulus (NS)
Conditioning phase:
White rat (NS)
→
Loud noise
Unconditioned stimulus (US)
After conditioning:
White rat
Conditioned stimulus (CS)
→
Response
Mild interest or curiosity
Neutral response (NR)
Fear and crying
Unconditioned response (UR)
Fear and crying
Conditioned response (CR)
In the experiment described in the box, Pavlov reasoned that the dogs had learned to
associate the sound of the bell with the actual food and thereby had been conditioned
to salivate (conditioned response: CR) to the bell, which had become the conditioned stimulus (CS). In this scenario, the food is the unconditioned stimulus (US)
which elicits salivation naturally, and salivation is the unconditioned response (UR).
In a study that would be deemed highly unethical today, Watson and Raynor
(1920) successfully conditioned a small child (Little Albert) to fear a white rat by
pairing presentations of the white rat with a loud and frightening noise. Although
Little Albert was initially curious about the rat, the loud noise ultimately caused
Albert to become fearful of the rat. Over time, Albert became fearful of many fur-like
objects, including his mother’s fur coat and Santa’s white beard, through a process
of stimulus generalization (conditioning generalizes to stimuli that resemble the
original). The classical conditioning paradigm is presented in Table 2.1.
Systematic desensitization Based on the underlying premise that one cannot be
anxious/fearful and relaxed at the same time, Wolpe (1958) devised a technique to
dissipate a fear or phobia gradually over a number of trials.
Systematic desensitization
The program consists of three steps:
1. Develop a fear hierarchy, a list of increasingly fearful images or activities
related to the fear, based on the individual’s subjective units of distress
(SUDs).
2. Train the individual in deep relaxation.
3. Beginning with the fear at the lowest level in the hierarchy, pair each of the
fears in the hierarchy with a relaxation response until the fear is mastered at
each level.
Systematic desensitization is one of a number of different exposure techniques
that have been developed based on principles of conditioning and learning. Another
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Clinical and Educational Child Psychology
successful technique is that of exposure and response prevention (ERP) which can
be used to treat individuals who engage in compulsive ritualistic behaviors. In this
treatment, individuals are exposed to their fears (such as fear of germs or contamination) and are prohibited from engaging in the compulsive ritual (such as excessive
hand washing, or cleaning rituals). Exposure techniques will be discussed at length in
Chapter 10, as they relate to the treatment of fears, phobias, and anxieties in children
and adolescents.
Operant conditioning While classical conditioning explains how we develop conditioned responses involving involuntary reflexes (salivation/eyeblink) or intense emotional reactions (fears and phobias), operant conditioning provides the framework
for understanding responses that are voluntary in nature. According to behavioral
principles of operant behavior, there are two possible explanations for increasing or
maintaining behavior: positive reinforcement and negative reinforcement.
Reinforcements are consequences that have a positive outcome and, as a result,
always increase the likelihood that a behavior will be repeated, since associations (contingencies) are formed linking the behaviors to these positive consequences. Consequences are positive if:
1. they add a positive outcome (positive reinforcement; for example, “when your
chores are finished you can watch television”), or:
2. they remove a negative outcome, thereby allowing the individual to avoid/escape
a negative consequence (negative reinforcement; for example, “if you come home
on time, you will not be grounded”). Negative reinforcement is often confused
with punishment; however, recall that reinforcement always increases behavior,
while punishment has the opposite effect.
Punishments are consequences that have negative outcomes and always decrease the
likelihood that a behavior will be repeated.
Consequences are negative, if:
a. they add a negative outcome (positive punishment; for example, “you are late and
you are grounded”), or
b. they remove a positive outcome and a penalty is levied (negative punishment; for
example, “if you stay out past midnight, I will take away your car keys”).
The positive and negative implications of the reward and punishment paradigm are
presented in Table 2.2.
If a behavior stops being rewarded altogether, or if it is severely punished, the
behavior will likely terminate, a condition known as extinction.
Behavior modification We can use principles of reinforcement and punishment, as
outlined in Table 2.2, to replace undesirable behaviors with behaviors that are more
acceptable. There are several methods that can be used to change or shape behaviors
and to sustain the improved behaviors over time, such as a token economy (e.g.,
Theoretical Models
Table 2.2
37
Operant conditioning: reinforcement and punishment paradigm
Goal
Add
Remove
Increase behavior
(for example, increase
homework behavior)
Positive reinforcement
Add a positive
If you do your homework, I
will buy you a pizza.
Decrease behavior
(for example, decrease
off-task behavior)
Positive punishment
Add a negative
If you don’t do your
homework, you will have to
stay after class, until it
is done.
Negative reinforcement
Remove a negative
If you do your homework, you
will not have to do the
dishes.
Negative punishment
Remove a positive
If you don’t do your
homework, you cannot go
outside to play with your
friends.
tokens are given for good behavior and can be exchanged for prizes at the end of
the day).
On the surface, behavior may not always be what it seems to be, as is evident in
the case of Erik (see box). In Erik’s case, a functional behavioral assessment (FBA)
could provide insight into what is causing and sustaining the behavior. Behavioral
techniques will be further addressed throughout the book as they relate to specific
problems discussed and in Chapter 5, where specific applications of FBA are discussed
at greater length.
The case of Erik: punishment gone awry
When Erik acts out in the classroom, his teacher “punishes” him by sending him
to the administrator’s office. Erik has been there three times this week. So why
is the punishment not working? For Erik, being sent to the office means that he
can avoid (escape) class work (negative reinforcement), and also reap the benefit
of added attention from office staff who chat with him (positive reinforcement).
It can be predicted that both consequences would serve to increase, rather than
decrease, his “acting out” behaviors in the future.
Modeling or observational learning In a classic experiment conducted by Bandura,
Ross, and Ross (1961), researchers witnessed young children abuse a “Bobo doll”
(an inflatable doll with sand feet, like a punching bag) after observing an adult acting
aggressively towards the doll. Peers who did not observe the aggressive adult, did
not demonstrate aggressive behaviors. Bandura and colleagues found that children’s
observations of behaviors could involve delayed imitation, where the child would not
respond immediately, but could carry forward earlier lessons observed. Observational
learning represents the third type of learning where information is observed and later
modeled or imitated.
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Clinical and Educational Child Psychology
Factors that increase the likelihood of
observational learning
Bandura (1986) has listed a number of elements that can increase the likelihood
that observational learning will occur, including:
r
r
r
r
attention (the action must be noticeable);
memory (the action must be memorable and retained in memory);
imitation (the learner must be able to imitate the action and sequence of
actions observed);
motivation (the desire to perform the action must be present).
A summation of the behavioral models The cardinal feature of the behavioral
model is that outcomes are based on the principles of learning. Within this context, a
child’s behavior has been either conditioned (if the response is an intense emotional
one, such as a phobia), or reinforced (positively reinforced or negatively reinforced,
since both serve to increase and sustain behaviors), or the child has observed the
behavior in others (i.e., the child is modeling the behavior). Behavioral interventions
are particularly well suited to children of younger ages, since teachers and adults
can monitor the programs and provide rewards for compliance, while children can
benefit from clear boundaries and an established set of rules to guide their behaviors. The behavioral perspective provides a systematic approach to the analysis of
problem behaviors and the development of appropriate intervention programs. In
some cases, such as fears and phobias, behavioral methods are often the treatment of
choice, while in other cases behavioral programs can provide an effective adjunct to
other treatments.
Cognitive models
The cognitive model provides insight into the nature and development of thinking
skills and how thoughts can influence behavior. Based on astute observations of his
own children, Jean Piaget (1896–1980) proposed a comprehensive theory of cognitive development that identified competencies, and limitations in reasoning ability,
based on faulty logic and inaccurate assumptions that exist at certain stages of development. While Piaget focused on stages of innate understanding, and how children
construct their own reality about their physical world, Lev Vygotsky (1896–1934) was
most interested in the social and cultural context in which the child’s cognitive skills
originated and how mentors could enrich the child’s understanding, by scaffolding
or guiding them to the next level of understanding. Theorists who support an information processing model to explain how we attend to and recall information have
used a computer framework to explain how information goes from the input stage
(sensory registers), to short-term memory and longer-term memory (Atkinson &
Shiffrin, 1968).
Social cognitive theorists have adapted the information processing model to explain
how faulty social information processing can lead to inappropriate behaviors based
Theoretical Models
39
on incorrect assumptions about others (Dodge, 1991). In the field of clinical psychology, cognitive theorists such as Aaron Beck (1976, 1997) have developed highly
successful programs for the treatment of depression and anxiety disorders based on
re-framing maladaptive thoughts and assumptions into healthy alternatives. Finally,
the field of cognitive neuroscience has made significant advances in the understanding
of the role of executive functions (the system that manages higher order cognitive processes, such as attention, cognitive flexibility, planning, abstract thinking, and
the initiation of appropriate responses while inhibiting inappropriate actions). Russell
Barkley (1997) has written extensively concerning the role of central executive function and problems of disinhibition in his model, developed to explain the breakdown
of these underlying processes in children who experience problems due to impulsivity
and/or hyperactivity.
Cognitive neuroscience and executive functions The role of executive functions has
received increasing attention in the explanation of child problems encountered in academic and social settings connected to specific learning disabilities, problems of attention and impulsivity, memory impairment, and a wide combination of other problems.
Barkley (1997) has developed a model to increase our understanding of the crucial role
that behavioral inhibition (the child’s ability to inhibit a response, or block a distractor) can exert on the success of executive functioning processes. According to Barkley,
if a child does not have the capacity for behavioral inhibition, then behavior is executed (stimulus → response) without the benefit of input from the executive processes
(working memory, internalization of speech, self-regulation of affect, and reconstitution) that are required to guide, plan, problem solve, and monitor reactions. As a
result, the child is unable to engage in goal-directed persistence or re-engage in tasks
when interrupted. The development of techniques to measure executive function, such
as the Behavior Rating Inventory of Executive Function: BRIEF (Gioia, Isquith,
Guy, & Kenworthy, 2000), has advanced our understanding about the potential processes involved and the nature of their impact on behavior. In the development of
the BRIEF, Goia et al. (2000) identified eight subdomains of executive function. Five
subdomains cluster together to provide a score for the Metacognition Index (initiate, working memory, plan/organize, organization of materials, and self-monitoring),
and three subdomains provide the composite score for the Behavioral Regulation
Index (inhibit, shift, and emotional control). Implications of the executive functions
for problems in a wide variety of areas will be addressed, as they apply, throughout
the book.
Social cognitive models Bandura’s (1977, 1986) contribution to the field of social
cognition stems from his early work on social learning processes that were previously
discussed under modeling and observational learning. As a result of Bandura’s (1977)
studies of the nature of social learning, we have developed an increased appreciation of
the positive consequences (nurturing and empathic caring behaviors) or negative outcomes (aggressive responses, for example, after witnessing domestic violence) that can
result. Furthermore, Bandura’s concept of triadic reciprocity advanced our understanding of the complex nature of the interrelationships between people, behaviors,
and the environment. The social cognitive model links the world of mental representations and problem solving to tasks where the goal is the increased understanding of
the self and others.
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Clinical and Educational Child Psychology
Social information processing Dodge and colleagues (Coie & Dodge, 1998; Crick
& Dodge, 1996; Dodge, 1991, 2000) have outlined six steps that occur when processing social information in a given social situation, including:
r
r
r
r
r
r
encoding social clues (selectively attending to social cues);
mentally representing and interpreting the cues (linking cues to previous experiences);
clarifying social goals;
searching for possible social responses (either from memory or formulation of new
response possibilities);
making a response decision (selecting a response based on an evaluation of probable
outcomes);
acting out selected responses, monitoring their effects and adjusting accordingly.
Researchers have found that some children with learning disabilities or aggressive
behaviors do not process social cues accurately, either by failing to consider information at one or more of the six steps, or by misreading social cues, such as inaccurately
attributing hostile intentions to others in ambiguous situations (hostile attribution
bias).
As a result, these children demonstrate weaker competence in social interactions
compared to their peers. The social information processing model will be revisited
in later chapters, as we discussion social skills problems and possible solutions and
interventions.
A summation of the cognitive models Understanding children’s cognitive limitations from a developmental perspective is essential to appreciating how children may
misconstrue events, and how to provide treatment programs that are suitable for a
child’s cognitive level. Furthermore, understanding the role of social cognition and
social information processing in strengthening or weakening social exchange is fundamental to positive intervention. Researchers have identified a number of behaviors
that indicate attempts at social exchange, or affective sharing and social referencing
(looking to the caregiver for cues in ambiguous situations) in normally developing
toddlers (Emde, 1992; Moses, Baldwin, Rosicky, & Tidball, 2001). These behaviors
are conspicuously absent in children with autism spectrum disorders who do not
engage in affective exchange due to deficits in social reciprocity and social pragmatics.
The impact of lack of reciprocity on development will be discussed at length in the
chapter on neurodevelopmental disorders (Chapter 7).
Cognitive behavioral therapy (CBT)
Cognitive behavioral therapy (CBT) is a form of therapy that is based on a theoretical approach founded on models of cognitive (thoughts) and behavioral (actions)
interventions. CBT is one of the most highly researched models of therapeutic intervention, as will become evident in the extensive references to CBT and its application
to numerous disorders throughout this book. Since the importance of this therapeutic
approach is evident in its application to a variety of disorders, further discussion of this
Theoretical Models
41
approach will be addressed as it relates to specific applications, as they are presented
throughout this book.
Psychodynamic models and attachment
Freud and the Neo-Freudians
Sigmund Freud developed his theories of repressed sexual urges as the basis for psychic
trauma based on his conversations with females during the Victorian era who presented
with many symptoms of hysteria (later labeled as conversion disorders). As a result,
Freud developed his psychosexual theory of development wherein he described
three parts of the personality that become integrated during five stages of development.
Freud’s theories on personality development and psychosexual stages The following provides a brief overview of Freud’s theories on personality formation and
psychosexual development.
Personality formation Freud’s structural model of personality formation was based
on conflict between desires, dictates of the conscience, and constraints of reality. The
model consists of three parts: the id (primitive sexual and aggressive urges seeking
gratification through the pleasure principle); the ego (the conscious part of our self
system driven by the reality principle and whose goal is to keep the id impulses under
conscious control); and the superego (our conscience that develops between three
and six years of age based on moral values internalized from our interactions with
our parents). Within this mode, it is the ego’s function to maintain a healthy balance
of compromises between the demands of the id and superego. Freud believed the
ego protected itself from battles between the id and the superego through the use of
defense mechanisms which are unconscious mental processes developed to alleviate
anxiety or bolster self-esteem. These defense mechanisms add depth to our understanding of more primitive child defenses, such as denial, or more socially constructive
defenses, such as humor.
Psychosexual stages Freud constructed his developmental model which linked libidinal drive to different erogenous zones (regions of the body that generate sexual
pleasure) based on his belief that libidinal drive (sexual pleasure) was the key to personality development. Freud’s model contains five stages, each representing a different
erogenous zone and the conflict or concerns generated at each stage. The stages, and
conflicts/concerns, are presented in Table 2.3.
Freud believed that too little or too much satisfaction or conflict might result in
adult forms of fixations or regressions based on earlier unresolved stages of conflict.
Freud’s psychosexual stages provide potential insight into unconscious drives and
conflicts which may influence the underlying dynamics of certain pathologies and will
be revisited within the context of the different disorders discussed in this book. Historically, psychodynamic applications have been difficult to support empirically; however,
influenced by Bowlby’s theories of self-development and attachment, recent research
42
Table 2.3
Clinical and Educational Child Psychology
Stages of psychosexual (Freud) and psychosocial (Erikson) development
Age range
0–18 months
2–3 years
4–6 years
7–11 years
12 + years
Freud’s psychosexual stage
Issues and conflicts
Erikson’s psychosocial stages
Task to be mastered
Oral stage
Dependency issues
Anal stage
Orderliness, control, compliance
Phallic stage
Identification with parent of same sex
(resolution of Oedipus Complex)
Superego evolves
Latency stage
Sexual and aggressive impulses are
sublimated
Genital stage
Mature sexuality and relationship
Trust vs mistrust
Satisfaction of basic needs
Autonomy vs shame and doubt
Increased physical independence
Initiative vs guilt
Increased independence and
emotional control, curiosity and
exploration
Industry vs inferiority
Increased productivity, self-concept
and competence
Identity vs role confusion
Sense of self and own identity
has demonstrated empirical support for play therapy programs that integrate psychodynamic concepts within the practice of psychodynamic developmental therapy for
children (PDTC) (Fonagy & Target, 1996; Lieberman, Ippen, & Marans, 2009).
Working through the medium of play, therapists assist children to develop skills in
the self-regulation of impulses and enhanced awareness of others. Lefebre-Mcgevna
(2007) applied a play therapy technique for traumatized children based on methods
of Dialectical Behavior Therapy (DBT), a hybrid of psychodynamic and cognitivebehavioral methods, and reported preliminary success with this procedure. Previously,
DBT has been found to be successful in treating adults with borderline personality
disorder (Linehan, 1987; Linehan & Dexter-Mazza, 2008).
Erikson’s psychosocial stages Erik Erikson (1902–1994) also supported the notion
of stages. However, unlike Freud, Erikson’s psychosocial stages were based on socioemotional tasks requiring mastery at various stages of development, in order to promote
positive growth across the lifespan, and contributing to our overall goal of understanding ourselves and others, and our role in society. Erikson believed that psychosocial
development continued over the course of our lifetime and he divided the lifespan into
eight different stages of man. Although we will only be discussing those stages that
relate to child and adolescent behavior, it is interesting to know that Erikson’s theory
contained three stages beyond adolescence, including: early adulthood (intimacy vs.
isolation), middle adulthood (generativity vs. stagnation), and late adulthood (egointegrity vs. despair). Erikson’s psychosocial stages, along with Freud’s psychosexual
stages, can be seen in Table 2.3. Psychosocial stages will be discussed further as they
relate to different milestones in development.
Mahler and object relations theory Crucial to the development of an individual
identity is the need to recognize that one must separate from the caregiver and
assume a separate identity. Mahler, Pine, and Bergman (1975) describe this process
of separation-individuation occurring in the first three years of life, as a process that
Theoretical Models
43
evolves from an initial lack of differentiation between caregiver and infant (normal
autism), to an increasing awareness of an individual identity and sense of self, moving
through several stages: the symbiotic phase, the differentiation phase, and the practicing
phase, culminating in the rapprochement phase at two years of age. In this phase,
toddlers must solve the dilemma of how to be independent without feeling vulnerable.
Finally, the young child achieves a sense of object constancy knowing intuitively
that a caregiver is available, if not in the moment, but on a constant basis. Based
on our understanding of different types of caregiver practices, it is readily apparent
that some children in situations of abuse or neglect may never achieve a sense of
object constancy with the caregiver. Next, Bowlby’s theory and Ainsworth’s studies
of attachment provide a greater understanding of the types of caregiver relationships
that can ultimately thwart the development of object constancy.
Attachment theory and models of attachment
Bowlby and adaptation theory John Bowlby (1907–1990) incorporated ideas
from several theories (ethology, systems theory, cognitive theory, and psychoanalysis) into his theory of attachment which provided a framework for understanding
the child’s social emotional development based on the degree of comfort and security
available in the first seven to eight months of the attachment relationship. Influenced by Freud’s concept of internal working models and Darwin’s survival theories,
Bowlby believed that the infant is “pre-wired” with a set of responses (crying, looking, clinging) to ensure survival, providing proximity maintenance (closeness to the
caregiver), a secure base, and a safe haven. A sensitive caregiver responds to an infant’s
calls of distress by soothing the infant and alleviating the infant’s stress, which sets the
stage for the development of the infant’s ability to self-soothe in times of stress. As a
result, a secure attachment provides a secure base for exploration resulting in increased
self-confidence, and provides the prototype for the infant’s internal working model
(IWM) for defining future social and emotional relationships as dependable and caring.
Attachment Bowlby believed that attachments formed within the first two years
of life carried a profound influence throughout the lifespan, as an internal working
model (IWM) for all future relationships. Mary Ainsworth, a student of Bowlby,
explored attachment issues using a procedure called the strange situation to observe
individual differences in the reactions of infants to their caregiver’s leaving and return
(Ainsworth, Blehar, Waters, & Wall, 1978). Based on the infant’s unique behavioral
responses, Ainsworth described a number of different attachment patterns for infants
who were securely attached or who demonstrated insecure attachment patterns. In
these studies, although securely attached infants would be distressed upon separation
from their mothers, they were able to be soothed by the caregiver upon return.
However, some infants demonstrated insecure attachment patterns such as anxious–
resistant attachment, also referred to as ambivalent attachment (distressed upon
leaving and unable to be soothed upon return) or anxious–avoidant attachment
patterns (ignoring the caregiver’s leaving and return). Researchers have determined
that infants with both avoidant and ambivalent attachments demonstrate more irritable
(fussy) behaviors than their securely attached peers (Pederson, Gleason, Moran, &
Bento, 1998).
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Clinical and Educational Child Psychology
Table 2.4
Patterns of attachment
Attachment pattern
Reactions to maternal
separation
Reactions to maternal
reunion
Child is distressed at mother
leaving
Child welcomes mother’s
return; child is readily
calmed by mother
Child is very distressed at
mother leaving
Child wants to be close to
mother but is angry and
irritable; child cannot be
calmed by mother
Child ignores mother’s
return
No predictable pattern; may
engage in rocking
behaviors, disoriented
Secure attachment
Insecure attachment
Anxious–resistant or
ambivalent
Anxious–avoidant
Disorganized–disoriented
Child ignores mother
leaving
Child appears dazed and
confused
Later, Main and Solomon (1990) discovered a fourth type of attachment evident in their population of children of abusive parents. Children who demonstrated
a disorganized–disoriented attachment style displayed no consistent pattern of
response but rather acted as if they were conflicted between an approach and an
avoidance pattern, appearing dazed and confused. The authors suggest that this disorganized attachment pattern results from inconsistent parenting which does not
provide the opportunity for infants to develop consistent internal working models
of how to relate to significant others. The different attachment patterns and likely
response to parent separation and reunion are illustrated in Table 2.4.
Strange situation experiments (Ainsworth et al., 1978)
In this procedure, infant behaviors are observed in a laboratory equipped
with one-way glass. There are eight steps to the experiment and behaviors
are recorded as the infant is separated from the caregiver on two different
occasions:
r
r
r
r
r
r
r
r
Baby and mother are alone in the lab play room.
Stranger enters.
Mother and stranger chat, briefly, and mother leaves.
Stranger leaves after a few minutes, leaving infant alone.
Mother returns and attempts to comfort the child.
Mother leaves again.
Stranger returns and attempts to comfort the child.
Mother returns and attempts to comfort the child.
Attachment theory emphasizes early infant experiences and the degree to which the
child is able to seek comfort from a caregiver in times of distress, thereby constructing
Theoretical Models
45
an IWM which becomes the underlying foundation for socio-emotional development. In a secure attachment relationship, the infant’s IWM predicts that distress is a
temporary state and the infant develops increasing skills in self-regulatory behaviors,
based on the premise that distress can be soothed and others can be depended on.
Securely attached infants are more independent and better problem-solvers than their
insecurely attached peers (Sroufe, 2002), while those who do not have consistent
access (physically or emotionally) to their primary caregiver are at risk for developing
self-representations as “unlovable and unworthy” (Cicchetti & Toth, 1998).
Parenting practices and family dynamics
Parenting style
In addition to early attachment patterns, researchers have also studied the impact of
parenting style on subsequent emotional and social development and parent effectiveness based on three areas: the degree of acceptance of the child and engagement in
the parenting process; the amount of control exercised; and the amount of autonomy
granted to the child (Hart, Newell, & Olsen, 2003). Based on her factor analysis of
parenting styles, Baumrind (1991, 2005) found two predominant categories of delineation: responsiveness and demandingness. According to Baumrind (2005), responsiveness refers to the extent to which parents foster individuality and self-assertion by being
attuned, supportive, and acquiescent to the children’s requests; it includes warmth,
autonomy support, and reasoned communication. Demandingness refers to the claims
parents make on children to become integrated into society by behavior regulation,
direct confrontation, and maturity demands (behavioral control) and supervision of
children’s activities (monitoring). Behavioral control and monitoring are modified in
their expression and effect on children’s development by parental support, reflectionenhancing communication, and psychological control (Baumrind, 2005, pp. 61–62).
Baumrind (1991) isolated four parenting styles related to the degree of structure
(demandingness) and warmth (responsiveness) inherent in the style. The authoritative parenting style provides strong feelings of warmth toward the children and
provides a good deal of structure and guidance. Those using an authoritarian parenting approach are overly controlling and rigid, and lack warmth in their harsh
parenting practices. Permissive parenting is associated with child indulgence, minimal structure or guidance, and few limits. Uninvolved parenting describes parents
who provide low structure and low warmth. Researchers have found that the different
parenting styles can predict different child outcomes. Parenting practice patterns are
summarized in Table 2.5.
Family systems theory
While the majority of theories evaluate child psychopathology from the perspective of
individual differences, theorists within family systems theory emphasize the family
unit as the focus of assessment and intervention, relating to several subsystems, such as
parent/child, marriage partners, siblings, or extended family. Within this context, the
focus is on the identified problem (often the child referred for behavioral problems)
as it relates to dynamics inherent in issues related to boundaries, alliances, and
power. If the spousal system is dysfunctional, then the response may be “scapegoating
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Clinical and Educational Child Psychology
Table 2.5
Parenting styles
Parenting style
Child outcomes
Structure or control
Warmth
Acceptance
Authoritative
Positive self-concept
High
High
Authoritarian
Anxiety and hostility
Low
Low
Permissive
Demandingness
High
High
Uninvolved
Dependency
High structure
Adaptive
High structure
Overly rigid and coercive
Low structure
Overindulgent
Lacking in structure
Negligent
Low
Low
of children or co-opting them into alliances with one partner against the other”
(Goldberg, Goldberg, & Goldberg Plavin, 2011, p. 420).
Boundaries are the imaginary lines that serve to define the various subsystems. Often
a family’s degree of dysfunction can be predicted by characteristics of boundary formation, which can manifest as weak limit-setting resulting from inconsistent or loosely
defined boundaries, or as lack of family engagement due to very rigid boundaries.
Children growing up in situations of loose boundaries may be privy to information
that is well beyond their years, in a family environment where family members are
enmeshed and overly involved in each other’s lives (Minuchin, 1985; Minuchin,
Nichols, & Lee, 2006). However, children who grow up in families where boundaries are overly rigid may experience a sense of detachment where family members are
disengaged. Within the family system, therapists often look for family assigned roles
(rescuer, victim, scapegoat, and so on) and how the balance of power is aligned. In
cases of conflict, often the dynamic of triangulation will be evident, as the balance of
power is weighted for two family members who align against a third member (e.g.,
mother and father vs. child, siblings vs. parents, mother and child vs. father).
Coercion theory Patterson, Capaldi, and Bank (1991) developed the concept of
coercion theory to account for the impact of coercive parenting practices on exacerbating children’s negative behaviors. In a theoretical framework that bridges the
behavioral and family systems models, Patterson et al. (1991) suggest that parents
who confront and then eventually yield to a child’s negative behaviors and demands
actually serve to increase the negative behaviors over time. Negative behaviors increase
because the behaviors are positively reinforced by the parent (the parent complies
and the child gets what he or she wants), while at the same time, the parent is negatively reinforced for their own compliance (the child’s negative behavior, such as
whining or tantrum behavior, ceases momentarily).
Coercion theory and reinforcement
Recall that positive reinforcement (the behavior is rewarded by a positive
consequence) and negative reinforcement (the behavior is rewarded because
it removes a negative event) both serve to increase behaviors. In this case, the
Theoretical Models
47
parent’s compliance is rewarded because the negative behavior stops (in the
short term) and the child’s negative behaviors (demands) are rewarded because
the goal is achieved. Parent and child become locked into a coercive cycle of
positive and negative reinforcement.
Therapeutically, the parent would be made aware of the dynamics inherent in this
reinforcement cycle and would be advised not to yield to the child’s demands and
to be consistent in not complying with unreasonable child demands. Over time, this
would serve to extinguish the child’s negative behaviors and break the coercive cycle.
The total child: an over-arching framework
Although it is important to recognize the various theoretical models that can be
applied to child psychopathology, it is equally important to see how these perspectives
can converge to provide an all-encompassing system that incorporates different models
into one over-arching framework.
A transactional ecological bio-psycho-social framework
Although debate in the past contrasted nature with nurture, contemporary researchers
are well aware that the contexts surrounding development can have a powerful influence on the degree to which human potential is realized. Urie Bronfenbrenner’s
(1979) ecological systems theory has been a crucial force in bringing about awareness of the importance of contextual influences on human development, and provides
the necessary organizational format for addressing information from the major theoretical perspectives in one over-arching framework.
Bronfenbrenner and the contexts of development Bronfenbrenner’s bioecological theory provides an ideal framework for discussing the interaction between child characteristics (genetics, temperament, neurological development) and environmental characteristics (proximal and distal sources) as seen in various levels of influence. In this
system, the child is depicted as the central figure in a series of concentric circles of
influence that emanate between the individual and the environment.
Within this model, Bronfenbrenner envisioned the layers of influence as bidirectional and interacting influences, characterized by their dual nature (i.e., influences are in two directions – both away from the child and toward the child). For
example, a given parenting approach may affect a child’s behaviors (poor limit-setting
may increase the child’s acting out behaviors). However, a child’s behaviors may also
influence parenting style (increased limit-setting to reduce acting out behaviors). More
recently, Bronfenbrenner has suggested that his model might best be characterized
as a bioecological model, in order to emphasize how the child’s biological characteristics interact with the different environmental factors (Bronfenbrenner, 2001;
Bronfenbrenner & Morris, 1998). Bronfenbrenner’s model is depicted graphically in
Figure 2.5.
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Clinical and Educational Child Psychology
Individual child: child
characteristics, biological,
genetic, temperament, IQ
Macrosystem
Microsystem: immediate
family, school, peers,
community, neighborhood
Exosystem
Exosystem: extended
family, social and economic
conditions
Microsystem
Macrosystem: culture,
values, and laws
Child
Figure 2.5 Bronfenbrenner’s bioecological model.
The ecological-transactional model (Bronfenbrenner, 1979; Cicchetti & Lynch,
1993) provides an over-arching framework for conceptualizing ecological contexts
“consisting of a number of nested levels with varying degrees of proximity to
the individual” (Lynch & Cicchetti, 1998, p. 235). Within this model, beyond the
individual there are three levels of environmental influence: the microsystem, the
exosystem, and the macrosystem.
Individual The individual child is at the core of the model, and internal factors emanating from biological and genetic sources contribute to strengths or vulnerabilities
that can enhance or inhibit a child’s interaction with all other levels/layers in the system. In a transactional model, child characteristics influence, but are in turn shaped or
modified in an on-going way by, the external factors. The biological model addresses
potential risk and protective factors, such as: maternal prenatal health and nutrition;
any medications or drug/alcohol use during the embryonic period; and family history
of psychopathology). Risks and protective factors will be discussed throughout the
book as they apply to the disorders discussed.
Microsystem The microsystem represents the primary relationships and interactions that a child experiences in his or her immediate surroundings. At this level,
bi-directional influences of family, school, neighborhood, and child care are seen to
exert the strongest and most direct influence on the developing child. The family
context is a primary source of influence during the early years and sets the parameters for a child’s concept of family and the roles of mother, father, and siblings.
In various cultures what defines the “family” can differ widely from the inclusion of
friends in the family circle to the exclusion of all but the immediate family. In many
African American families, grandmothers play a major role in child-rearing (Cain &
Theoretical Models
49
Combs-Orme, 2005), while in Asian families female family members (grandmothers
and aunts) and older siblings may play an increasing role in care-giving over time
(Kurrien & Vo, 2001). Furthermore, the influence of individualism versus collectivism (Hofstede, 1980) can play a major role in whether the family dynamics support
the individual (independence, autonomy) versus the group (fostering group cohesion
and cooperation).
Individualism versus collectivism
In an individualistic society, independence and autonomy are revered, and individuals relate to those outside the family, usually in loose associations through
shared interests and activities. In a collective society, in addition to very strong
loyalty and ties to family, individuals have strong ties to “in groups,” such as
extended family. Group participation outside the family is limited to a select
few permanent groups. Within this context, the United States and the United
Kingdom would be considered individualistic societies, while Asia and Central
America would be considered collectivistic.
Family systems are also subject to change, with the advent of new siblings and
the possible dissolution of a marriage. The impact of a chaotic environment at the
microsystem level will be discussed in Chapter 6, as it relates to child and adolescent
adjustment difficulties experienced due to family dynamics, psychosocial turmoil, and
problems in the school environment.
The quality of the child’s school day care setting (e.g., primary school) can have
an important influence on development, as can the peer group that the child relates
to within these settings. In North America, formal schooling begins at age six and
children will spend six hours a day during the week in their school setting. In Western
Europe and Japan the time spent in school is even longer. The transition to primary
school and high school can be a difficult time for most children and adolescents,
since it marks the entrance into a new set of circumstances and influences. Finally, the
neighborhood itself (access to resources and recreation, neighbors, safety, and quality
of neighborhood upkeep) can also influence the developing child, for better or worse.
The influence of school transitions, as well as other challenges, such as peer group
affiliations, and quality of neighborhood will be addressed in Chapter 6. Within the
microsystem, the degree of communication or compatibility between the structures
can strengthen or undermine the influence of either factor. Bronfenbrenner used
the term mesosystem to refer to the degree of connection/communication between
factors in the microsystem.
Mesosystem effects
The quality of communication between individuals in the child’s microsystem
can have important effects on development. For example, if parents (home) and
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Clinical and Educational Child Psychology
teachers (school) communicate regularly and share the same goals for the child,
the potential for academic success will increase significantly, since the two factors
support each other. Conversely, poor communication between home and school
has been associated with increased risk for academic difficulties.
Although the microsystem represents the most proximal source of influence,
interactions at more distal levels can also impact the inner structures positively or
negatively.
Exosystem The exosystem consists of factors related to the social and economic
context, such as a parent’s employment situation, and the socioeconomic status
of the family, and the extended family. Although this level does not impact the
child directly, one can readily imagine how a parent’s work stress might impact
a child, or conversely, how a child’s ill health might impact on a parent’s work
situation (increased absenteeism due to child care needs). Studies have demonstrated that poor access to community resources can also have a negative effect
on development and place children at risk for negative peer relationships (Jones &
Offord, 1989).
Macrosystem The outer sphere of influence is the macrosystem which involves
cultural values, customs, and laws, and can have a ripple effect of a cascading influence throughout the inner spheres. For example, a change in education law can
ultimately have a direct impact on educational instruction for a child with special
needs. Similarly, a parent’s rigid adherence to cultural values that conflict with an adolescent’s peer group in a new country may cause significant turmoil for the child and
his family.
A transactional ecological bio-psycho-social framework: a summation Ultimately, the quality of these contexts and interactions will influence the nature of child
and adolescent development and the learning and acquisition of skills necessary for
successful adaptation and communication. Increased understanding of the on-going
and transactional nature of the process of development brings with it an appreciation
of how changes within the child can result in transformations in the environment at
all levels depicted above, and that conversely, changes at all levels of influence can
impact the growing child.
Our knowledge of skill development in cognitive, emotional, and social areas and
our understanding of predicted patterns of behavior not only provides a blueprint for
change, but also gives the necessary benchmarks required to evaluate the degree to
which an individual’s developmental trajectory adheres to or deviates from the norm.
In the next chapters, we will take a closer look at milestones for cognitive, emotional,
and social development as they unfold during early and later childhood (Chapter 3)
and adolescence (Chapter 4).
Theoretical Models
51
References
Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment.
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3
Developmental Milestones: Early
and Middle Childhood
Chapter preview and learning objectives
Biological beginnings
Neurological and physical/motor development
Neurological development
Physical and motor development
Genetics and heritability
Milestones in cognitive development
Piaget and cognitive stage theories
Stages of moral reasoning
Strengths and limitations of cognitive stage theories
Vygotsky and facilitated learning
Milestones in information processing
Milestones in self-awareness and self-control
Development of self-awareness
Development of self-control or behavioral self-regulation
Milestones in emotional development
Understanding emotions
Emotions and interpersonal aggression
Milestones in psychosocial development
Understanding others and social exchange
Attachment, parenting style, and child outcomes
The attachment process
Child outcomes associated with attachment patterns
Attachment and intervention
Parenting style and child outcomes
Baumrind’s four parenting styles and child outcomes
Culture, SES, and parenting styles
Parenting practices, parenting styles, and child outcomes
References
Clinical and Educational Child Psychology, First Edition. Linda Wilmshurst.
© 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.
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Developmental Milestones: Early and Middle Childhood
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Chapter preview and learning objectives
Although it is recognized that development continues across the lifespan with ongoing change in mental health and lifelong learning, it has also been acknowledged
that growth in the latter stages of development (early, middle, and late adulthood)
progresses at a significantly slower pace than in childhood or adolescence. Furthermore, changes in later life often focus on the consolidation of previously acquired
foundation skills, rather than the acquisition of new skills and competencies.
This chapter focuses on the initial years of the acquisitive stage (Schaie & Willis,
1993), which spans childhood and adolescence; a time when the major task is to
amass information that will be effectively applied in later stages of development.
Rapid rates of growth in these formative years can produce significant changes that
can have profound influences on a child’s responsiveness to the environment and,
ultimately, the social and emotional lessons learned along the way. It is important that
practitioners working with children have a good understanding of expected time-lines
for the acquisition of different competencies and skills, or they risk missing valuable
opportunities for early intervention initiatives, and for designing programs that are
developmentally appropriate.
This chapter focuses on the milestones in development that provide benchmarks
of increasingly complex skills, in cognitive, affective, and social development, in early
and middle childhood. Adolescent milestones will be discussed in Chapter 4. After
reading this chapter, readers will have a greater appreciation of:
r
r
r
r
r
r
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r
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biological influences on the neurological and physical/motor development of the
child;
brain anatomy, structure, and function relative to child development;
milestones and gender differences in physical maturation;
the role of genetics and heritability in individual differences in development;
milestones in cognitive development from the dual perspectives of stage theory
and information processing;
expectations for increased self-awareness and self-control across the developmental
spectrum;
milestones in understanding emotions in the self and others in the developing
child;
the role of attachment in social, emotional, and affective development;
the impact of parenting practices on outcomes for child development.
Biological beginnings
Neurological and physical/motor development
Neurological development
Brain development The infant’s brain weighs approximately 350 grams, which is
equal to about 25% of its adult weight (Morgan & Gibson, 1991). By two years of
age, the child’s brain will have tripled in weight (70% of its adult weight) and by six
years of age, the brain will reach 90% of its adult weight (Thatcher, Lyon, Rumsey, &
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Clinical and Educational Child Psychology
Krasnegor, 1996). As was discussed in Chapter 2, initially, the brain is actively involved
in creating new neural networks and pruning pathways that are no longer useful or
stimulated. In the first two years, glial cells produce myelin, a fatty sheath that coats
the neural fibers and increases the efficiency of the message transfer between neurons.
As a result, preschoolers rapidly improve their skills in a wide variety of areas, including
coordination, perception, attention, memory, and language.
Between three and six years of age there is rapid growth in the frontal-lobe areas
of the brain associated with planning and organization. During the preschool and
school years, increased impulse control, planning ability, and problem solving are
related to development in the prefrontal cortex. Initially, the brain is highly plastic,
which means that the cerebral cortex has not yet designated different hemispheres for
specialized functions, a process which is called lateralization. For example, studies of
early brain damage have demonstrated that regardless of where the injury is located
(the left or right side of the brain), language delays can result, and remit by early school
entrance, suggesting that language is not lateralized in very young brains. However,
damage to the right hemisphere (spatial processing) can result in long-term disabilities
in processing visual spatial information (Stiles, 2008), such as the type of processing
deficits that are experienced by children with nonverbal learning disabilities (Rourke
et al., 2002) which will be discussed in Chapter 8.
Lefty or righty?
There is heightened activity in the left hemisphere of the brain between three
and six years of age, when language acquisition is at its peak. Activity in the right
hemisphere (which deals with spatial abilities) continues to increase throughout
middle childhood (Thompson et al., 2000). Hand preference is clearly established in 90% of children by five years of age (Ozturk et al., 1999). Studies have
revealed that right-handed dominance is primarily associated with a dominant
left hemisphere. However, for those who are left-handed (10% of the population), language functions are often shared between the two hemispheres (Knecht
et al., 2000). As a result, left- or mixed-handed children are more likely than their
right-handed peers to develop superior verbal and mathematical skills, likely due
to the use of both hemispheres to process cognitive information (Flannery &
Liederman, 1995).
Other brain functions The cerebellum, responsible for smooth muscle movements, continues to myelinate until the child is approximately four years of age, which
is evident in increased balance and control (Tanner, 1990). Myelination of the reticular formation continues throughout this period and into adolescence, providing
increased attention and concentration. Throughout childhood and into adolescence,
myelination increases the efficiency of the corpus callosum, which integrates information from many sources, including memories, attention, perception, language, and
problem solving (Thompson et al., 2000).
Developmental Milestones: Early and Middle Childhood
57
Physical and motor development Physical growth is dramatic during the early years,
with gross motor skills (large muscle movement, such as throwing a ball) developing
prior to fine motor skills (smaller movements, such as holding a pencil). By their
third birthday, children have amassed a number of motor skills, including jumping,
hopping, and skipping. By five years of age, most children can master the ability to ride
a bicycle, climb a ladder, and engage in athletic activities such as skiing, skating, soccer,
and baseball. School-aged children have increased control over their muscles and
demonstrate enhanced gross motor coordination in their agility, flexibility, balance,
and force (Cratty, 1986).
Fine motor skills also continue to improve with practice and mastery of fine motor
movements. What started as a scribble at 18 months, can be perfected into a drawing
of a circle and square by three years of age, and a recognizable person by four years of
age. By six years of age, most children have mastered the ability to print the letters of
the alphabet, the numbers from one to 10 and their initial and last names. Drawings
take on increasing sophistication, and by nine to 10 years of age, drawings are more
complex in detail and begin to integrate concepts of depth perception and perspective.
Assessments of developmental functioning in young children often include instruments to evaluate perceptual and motor skills, such as the Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI-6; Beery, Beery, & Buktenica, 2010)
which is now in its sixth edition. The test requires the child to reproduce a number of
increasingly complex designs which can be scored to determine how the child meets
developmental expectations.
Gender and physical maturation Until approximately 10 years of age, boys and
girls demonstrate similar rates of physical and motor growth evident in increased
motor control and coordination, as well as enhanced physical strength and agility.
Sexual differentiation begins soon after conception, as the presence or absence of the
male hormones (androgens) determines whether male or female sex organs develop.
Androgen levels remain relatively constant throughout early childhood but begin
to rise again in middle childhood in preparation for the physical development that
accompanies puberty.
Genetics and heritability A significant question that has its roots in the nature/
nurture controversy is the degree to which traits and characteristics such as brain
structure, chemistry, and function are inherited. Twin and adoption studies have
provided information about the risks of inheriting a genetic vulnerability to developing
depression, anxiety, attention/concentration problems, or learning difficulties such as
dyslexia.
Is intelligence a product of nature or nurture?
Gardner (1999) addresses this question, suggesting that it is primarily a question
generated by Western societies, since collectivistic Eastern societies downplay the
role of individual differences. However, based on twin studies, IQ is predicted
by intellectual scores obtained by birth parents, not adoptive parents.
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There is growing research support of the interaction between genetics and the
environment, such as the finding that prolonged exposure to trauma and abuse in
infants can impact how the brain is genetically wired for future hyper-responsiveness
to stress (Beers & DeBellis, 2002). In Chapter 6, common stressors and developmental
responses to stress will be addressed.
The role of temperament Allport (1961) noted that temperament was “dependent
on constitutional make-up and (was) therefore largely hereditary in nature” (p. 34).
Since that time, there has been considerable controversy over whether temperament is
determined more by heredity or environment. Temperament, like personality, defines
consistent patterns of behavior (strength, speed, and nature of response, and so on)
that predict how an individual is likely to respond in a given situation. Furthermore,
most behavioral traits are considered to be relatively stable by the end of the infant
stage. Although some traits can be learned, researchers have found support for a
genetic basis for some characteristics, like wariness/shyness (Kagan, 1992), or being
inhibited and experiencing negative emotions (Plomin, 1994). In studies of “high
reactive” and “low reactive” infants, these characteristics are considered to be biologically based (Kagan & Fox, 2006; Kagan & Snidman, 2004) and related to level of
excitation in the amygdale and associated structures.
Is biology our destiny?
Kagan poses this question in a film clip featuring his work on temperament
and infant responsiveness to stimulation (http://www.youtube.com/watch?
v = CGjO1KwltOw). He states that although we may be born with tendencies
to react in certain ways, parents can guide the wary child with a gentle push to
be more social, and can improve their potential for social engagement.
Milestones in cognitive development
Piaget and cognitive stage theories
Piaget identified five periods of development based on competencies and limitations
in thinking and problem solving.
Sensorimotor period The sensorimotor period spans the first two years of life, and
ushers in a number of significant cognitive milestones, such as object permanence,
an understanding that objects continue to exist even when they are out of sight.
This awareness paves the way for symbolic learning and early representational thought
evident in the child’s increased ability to demonstrate deferred imitation and engage
in make-believe play. In Chapter 7, readers will find that children diagnosed with
pervasive developmental disorders (PDD), such as the autism spectrum disorders
(ASD), demonstrate a qualitative impairment in communication which is often lacking
in spontaneous, make-believe, or imitative play. The major milestones and limitations
during the sensorimotor and preoperational periods are summarized in Table 3.1.
Developmental Milestones: Early and Middle Childhood
Table 3.1
59
Cognitive milestones: early childhood (birth to seven years of age)
Developmental period
Milestones/ limitations
Birth–2 years
Piaget: sensorimotor
period
Object permanence (objects continue to exist when hidden)
Intentional goal-directed behavior
Deferred imitation
Make-believe play
Information processing
Recognition memory (known as familiar)
Perceptual organization (categorization by perceptual features)
Recall memory (mental image)
Conceptual organization (organize by category, usage)
2 –7 years
Piaget: preoperational
period, early stage
Milestones:
Sociodramatic play (include others in make-believe play)
Can sort objects into familiar categories
Limitations in thinking:
Egocentrism (inability to take viewpoint of another)
Animism (inanimate objects given real-life qualities)
Illogical thinking (cannot solve class inclusion problems)
Centration (inability to consider more than one factor at a time)
Conservation (inability to conserve; lack of irreversibility)
Appearance/reality (inability to distinguish)
Preoperational period,
later stage
Milestones:
Increased understanding in all above areas
Can perform conservation of number tasks
Information processing
Increased attention span
Numbers: simple addition, subtraction, and counting
Can repeat 4 digits
Formation of autobiographical memories
Preoperational period Despite significant cognitive advances, children in the early
stages of the preoperational period (approximately 2–6/7 years) have several limitations in their thinking, including egocentrism which is the inability to take the
perspective of another. Early studies focused on the child’s inability to predict what
another would see from a given perceptual vantage point (matching the correct view
of three mountains from where a doll was sitting); however, later studies expanded this
notion to include the child’s inability to take another’s social or emotional viewpoint
(i.e., empathy).
A second major limitation at this stage is the child’s inability to solve problems
involving principles of conservation. These problem-solving tasks require the child
to reason that actual properties of number, mass, length, and volume remain constant
despite changes in physical appearance. Examples of conservation experiments are
available in Table 3.2.
In the first example in Table 3.2, children in the preoperational stage will respond
that the row with the blocks stretched out has more blocks, even if they responded that
the rows were the same, earlier. Piaget reasoned that children in the preoperational
period make this error in judgment due to their inability to decenter (focus on more
than one aspect of the array at a time). As a result, the child is unable to reason that
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Table 3.2
Examples of Piaget’s conservation tasks
Type of
conservation
Method
Initial presentation
Method
Transformation
Age of
mastery
Conservation
of number
Is there the same number of
blocks in each row?
Is there the same number of
blocks in each row? If not,
which one has more?
6–7 years
Conservation
of liquid
Is there the same amount of
water in each glass?
Is there the same amount of
liquid in each glass, or
does one have more?
6–7 years
A
B
A
B
C
D
Conservation
of length
Is each of these sticks just as
long as the other one?
Are the two sticks each as
long, or is one longer
than the other?
7–8 years
Conservation
of mass
Is there the same amount of
clay in each ball?
Do they still have the same
amount of clay, or does
one have more?
7–8 years
objects or situations remain stable (are conserved) despite alterations in their superficial
or visual appearance.
The curious case of Maynard: the cat who became a dog
In a landmark study by DeVries (1969), children (three to six years of age)
were asked to identify if Maynard was a cat or dog prior to playing with the
animal. As would be anticipated, all the children correctly identified Maynard as
a “cat.” However, following the play period, the researcher placed a dog mask
on Maynard and asked the children, once again, if Maynard was a cat or a dog.
Almost all of the three-year-olds now claimed that Maynard was a “dog.”
Developmental Milestones: Early and Middle Childhood
Table 3.3
61
Cognitive milestones: school age to pre-adolescence
Developmental period
Milestones/limitations
7–11 years
Piaget: concrete
operational period
Mastery of conservation tasks:
Substance/mass (7–8 years), length (7–8 years), area (8–9 years),
weight (9–10 years)
Classification and class inclusion
Seriation (order objects by length or weight)
Theory of mind
Increased understanding of metacognition
Information processing
7–8 years
Improved selective attention
Rehearsal as a spontaneous memory strategy
Can repeat 5 digits
Increased use of classification skills
Increased flexibility of attention
9–11 years
Increased planning
Metamemory: memory strategies increase (organization,
elaboration)
Can repeat 6 digits
Increases in cognitive self-regulation
(monitoring progress towards a goal, readjusting plan accordingly)
Increased speed and efficiency of processing
The inability to consider more than one dimension simultaneously also accounts
for problems experienced with issues of appearance and reality.
Faulty logic is also demonstrated in problems involving class inclusion because
children at this stage do not understand that a subcategory cannot contain more
items than the superordinate category. For example, if a child is shown a picture of
cows and horses in a field, and the cows (10) clearly outnumber the horses (2), when
asked if there are more cows or animals in the field, the child at this stage will answer
“more cows.”
Concrete operational period Following a transition period (between five and seven
years), when children are prone to make inconsistent responses, school-age children
can respond to the majority of conservation tasks correctly, with a good degree of
confidence in their responses, and can provide a rationale based on observable facts
(e.g., glasses contain the same amount of liquid, since only the shape of the container
has changed). However, even at this stage, children are still limited by what is observable and concrete and they cannot engage in problem solving of a hypothetical nature.
Milestones for the concrete operational stage are available in Table 3.3.
Formal operations Finally, entrance into the stage of formal operations places the
adolescent within the realm of adult reasoning and logic. For Piaget, the ability to
think in the abstract is the cornerstone of this period which allows the adolescent
to perform tasks requiring hypothetical and deductive reasoning, which will be
discussed in Chapter 4.
Stages of moral reasoning For Piaget, moral reasoning evolves over the course of
two broad developmental stages. The first stage, heteronomous morality or moral
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realism (ages five to 10), is dominated by a sense that rules are created by authority;
laws are not changeable and obedience is essential. At this stage, children do not
consider “intention” and focus exclusively on the outcome. Based on developmental
responses to a series of moral dilemmas, Kohlberg (1976) proposed a stage theory
of moral development that is closely aligned with Piaget’s ideas that moral reasoning
is closely tied to limitations in cognition. Kohlberg’s first stage of moral reasoning,
preconventional morality, reflects early childhood concepts of doing the right thing,
based on the consequences; for example, we want to avoid punishment or obtain a
reward. Later on, in middle childhood, the concept of morality is represented by what
Kohlberg labeled conventional morality, where the correct moral response is dictated
by what is the expected response given the standards prescribed by the group; that is,
doing the right thing and maintaining the status quo. For Kohlberg, the final level,
postconventional morality, which will be discussed in the next chapter, was achieved
by a select few. Kohlberg’s stages of moral development are available in Chapter 4,
Table 4.1.
Accident or purposeful act?
John is helping his mother set the table and he accidently breaks five plates.
George is upset and throws his plate on the floor, breaking it.
Which child is naughtier, John or George?
A young child would not consider the intent and would say that John is naughtier
because he broke more plates.
Strengths and limitations of cognitive stage theories Although there is agreement that
stages occur in the sequence Piaget suggested, rates may vary; for example, the pace
may be accelerated (in the case of giftedness) or slower (in the case of cognitive
delay). In addition, while Piaget believed that cognitive development was universal,
there is growing evidence that children in different cultures develop skills in different
ways (Chavajay & Rogoff, 1999; Rogoff & Chavajay, 1995). For example, Piaget’s
stages apply more to children who attend traditional schools, compared to tribal
children without formal schooling (Fahrmeier, 1978). Piaget’s theory is also criticized
by researchers who believe that several of the milestones occur much earlier than
originally thought. For example, using a technique that focuses on impossible events,
Baillargeon and colleagues (Aguilar & Baillargeon, 2002; Baillargeon, 1993, 2008)
have demonstrated the existence of object permanence in infants as young as five
months of age.
Kohlberg’s theories of moral development have also been criticized for not recognizing gender differences in moral thinking. Gilligan (1982) has suggested that
females are more prone to make moral decisions based on the perspective of “care”
(affection and mutual trust), while males are more likely to make their moral judgments based on “justice,” although these suggestions have not been supported by
research (Turiel, 2006).
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63
Vygotsky and facilitated learning
Although Piaget focused primarily on learning through self-discovery, Vygotsky
believed that learning could be enhanced by social facilitation and such strategies
as scaffolding, where the adult or mentor provides guided participation (Rogoff,
2003) to raise performance to the next level. Children demonstrate improved skills in
planning and problem solving when more skilled mentors (adult or peer) are involved
(Kobayashi, 1994). For optimum learning to take place, those providing the assistance to the learner should have an understanding of the child’s zone of proximal
development (ZPD), or the optimum level of intervention that is just within the
child’s grasp (not too difficult or too easy). Within this context, it is also important
to know when to withdraw assistance to allow the child time to consolidate the newly
acquired skills (Tudge & Rogoff, 1999). When parents use scaffolding techniques,
children demonstrate an increased capacity to concentrate and focus at an early age,
and greater social and academic maturity later on (Bono & Stifter, 2003; Ruff &
Capozzoli, 2003).
Milestones in information processing
Studies of information processing focus on the child’s growing capacity in attention,
memory, and problem-solving skills. Selective attention, concentration, and flexibility
in engaging and disengaging attention from the task at hand improve over the course of
childhood. In Chapter 8, the discussion focuses on children and youth who experience
problems with attention and concentration due to executive functioning deficits that
impair their ability to inhibit responses and sustain goal-directed behaviors. Individuals
with attention deficit hyperactivity disorder (ADHD) have less activity in the prefrontal
area of their brain, which is associated with planning ability and the ability to shift
attention between different tasks (Barkley, 1998).
As early as three to five years of age, children who are able to inhibit responses
perform better on tasks of math and reading achievement later on (Blair & Razza,
2007). Studies using functional magnetic resonance imaging (fMRI) techniques have
found increased activation of the prefrontal cortex (associated with planning ability)
at this stage of development when young children are engaged in tasks that require
the need to inhibit inappropriate responses (Bartgis, Lilly, & Thomas, 2003).
Increasing awareness of the theory of mind (awareness that others have their own
thoughts and perceptions), metacognition (thinking about thinking), and metamemory (awareness of the different strategies available to assist recall) all contribute to a
refined ability to process information over the course of development.
Children with autism spectrum disorders (ADS), which will be discussed in Chapter
7, experience significant difficulty with theory of mind problems (also known as the
false belief test), although those with higher functioning autism (HFA) may acquire
the ability at a later stage of development.
Children develop an increased capacity for cognitive self-regulation (the ability
to monitor and alter strategies when needed in order to meet one’s goals). Young
children who use private speech (or self-directed speech) on challenging tasks perform better than peers who do not (Winsler, Naglieri, & Manfra, 2006). The use
of private speech eventually lessens with age; however, children who experience
learning and behavior problems tend to engage in self-directed speech beyond their
age-mates, most likely in an effort to sustain their focus in light of their attention
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and processing problems. Children who do not increase their cognitive self-regulation
skills are at risk for negative outcomes in all areas of functioning, including: learning,
academic performance, and social/emotional development. Milestones in information
processing are available in Tables 3.1 and 3.3.
Theory of mind
Brenda and Meredith are sharing crayons from the wooden crayon box at the
play table. The teacher asks the girls to put the crayons back in the box and
close the lid. Brenda is sent out of the classroom to do an errand. While Brenda
is gone, the teacher replaces the crayons with chalk and asks Meredith the
following question: When Brenda returns to the room, what will she say is in the
wooden box? If Meredith has acquired a theory of mind, she will state “crayons,”
because Brenda was not privy to information about the exchange. However, if
Meredith does not yet have a theory of mind, her response will be that Brenda
will say there is chalk in the box.
Milestones in self-awareness and self-control
Development of self-awareness
An examiner places red rouge on a child’s nose; at what age will the child first touch
his nose when viewing his image in the mirror? Lewis and Brooks (1978) found that
approximately 75% of children between the ages of 21 and 24 months will respond
to their own nose, rather than the reflection in the mirror, indicating a sense of
visual self-concept (perceptual self) or self-recognition. Self-recognition is related to
cognitive development and is delayed in children with Down syndrome (Cicchetti &
Beeghly, 1990).
Toddlerhood Erikson recognized the major task for mastery at this stage of psychosocial development was autonomy versus shame and doubt. In this stage, children can be non-compliant and negative, traits that have come to define the “terrible
twos.” However, opposition is less evident in families that practice warm parenting
and guidance (Kochanska, Tjebkes, & Forman, 1998). Self-descriptions, at this stage,
usually contain references to age, gender, and physical size.
Preschool and early childhood During this stage (three to six years), Erikson
believed the major task was initiative versus guilt as preschoolers develop a sense of
purposefulness and self-efficacy (Bandura, 1995) resulting from increased experiences
of mastery. However, overconfidence can be an issue, as children tend to overestimate
their abilities and underestimate the difficulty of the task (Harter, 1998). Preschoolers
develop a sense of self–representation based on their own sense of personal attributes
(Eder & Mangelsdorf, 1997) and often describe themselves in terms of their physical
activities (“I like to run”) and possessions (“I have a new red truck”). The development
Developmental Milestones: Early and Middle Childhood
65
of self-concept (attributes, competencies, values) evolves over the course of childhood
and eventually is accompanied by a sense of self-esteem (evaluations of one’s own
worth and the associated feelings). The impact of parenting practices and attachment
style on the child’s developing sense of self-esteem will be discussed at greater length
later in this and the following chapter.
In early childhood, children begin to associate themselves with concrete categories
and in addition to providing information about their possessions (“I have a new red
bike”) and their abilities (“I can make a car out of Lego”), they now add being part of
a group to their description (“I go to preschool and I live with my mommy and sister”).
Middle childhood Erikson saw this as a time to master industry versus inferiority,
which becomes evident as there is an increased tendency to include the social self
(Damon & Hart, 1988) in self-reports (e.g., “I am a girl scout and I am a member of
the soccer team”) and to use social comparison to gauge performance. At this stage
(seven to 10 years of age), children describe themselves by reference to their internal
attributes (thoughts, feelings) as well as their external characteristics and abilities
(Harter, 1998). For example, when asked to describe herself, Monica might say:
“I have blonde hair and blue eyes. I am a great speller. I don’t do math very well. I am a
kind person and I can sing a lot better than my brother.” Middle childhood is a time when
gender differences contribute to individual variations in self-perceptions; for example,
boys tend to rate themselves equally along dimensions of social, scholastic conduct,
appearance, and athletics, while girls tend to rate themselves lower for categories of
appearance and athletics than males (Bukatko & Daehler, 2004).
Development of self-control or behavioral self-regulation
Children who demonstrate self-regulation have an ability independently to monitor
and control their behaviors appropriate to the given situation (Grolnick & Farkas,
2002). Children’s “effortful control” or ability to regulate their behaviors (behavioral self-regulation) and their emotions (emotion regulation) increases dramatically between two-and-a-half and three years of age due to rapid development of the
prefrontal cortex (Rothbart & Bates, 2006; Thompson & Goodvin, 2007). This development also results in more consistent responses to environmental stressors through
increases in the inhibition of impulses and increases in attentional control (Li-Grining,
2007).
Early childhood to preschool Temper tantrums peak at three years of age, then
dissipate as children develop increased coping skills which allow for increased maturation in frustration tolerance. At the same time, willfulness and non-compliance are
increasingly replaced by cooperative behaviors generated to please adults, as children
begin to internalize parental values and are motivated to gain their parents’ approval
(Kochanska, Aksan, & Keonig, 1995). Delay of gratification is also improving, aided
by children’s ability to use a number of self-initiated strategies, such as self-distraction
(looking away, self talk, singing) to alleviate the frustration of waiting to obtain a coveted reward, such as opening a present or eating a treat (Wolf, 1990). Researchers
have found that girls, who have more advanced development of attention and language skills, perform at a higher level than boys, evidencing greater self-control in
these tasks (Else-Quest, Hyde, Goldsmith, & Van Hulle, 2006).
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Caregivers can increase their child’s ability to regulate behaviors by encouraging
patience and rewarding compliance, especially in the case of young children who tend
to be more reactive. Kochanska, Aksan, and Carlson (2005) found that when caregivers
used encouragement and assurance with reactive toddlers, their skills improved when
assessed again, several months later; however, if parents were impatient, these toddlers’ reactive behaviors intensified on later evaluation. Researchers have consistently
found that the goodness of fit between a child’s temperament and environmental
conditions (such as parenting style) can have positive outcomes (increased compliance
and self-regulation) or negative outcomes (increased anxious and reactive responses
and reduced self-regulation) for the developing child (Feldman, 2007).
The importance of self-regulation of emotions and behaviors cannot be overstated,
as will become evident in future discussions of adaptive and maladaptive responses to
frustration, aggression, and learning, and in the context of social situations. When these
milestones are not achieved, this can result in many negative outcomes, academically,
socially, and emotionally. Children who achieve these milestones continue along a
path of increased maturity and social acceptance, while those who do not become at
increased risk for social isolation, peer rejection, and depression.
Summation The rapid development of the prefrontal cortex during the latter half of
the toddler period and in the preschool years provides the foundations for increased
ability to regulate behaviors and emotions (Rothbart & Bates, 2006). This increased
capacity within the context of a supportive environment helps prepare the child for
primary school with a sense of confidence, competence, and readiness to be successful
in school both academically and socially.
However, some children enter primary school ill-equipped to face the challenges in
their school environment due to poor ability to regulate their emotions or behaviors,
and an inability to focus and attend to the tasks at hand. These children can become
readily overwhelmed by their lack of success on a daily basis, and are at greatest risk
for developing the disorders of childhood and adolescence which are the focus of Part
Two of this book.
Ego resiliency
Ego resiliency (the ability to monitor and alter behavior to suit the situation) also
emerges with greater consistency during the latter half of the toddler period and
the preschool years, as self-control leads to increased management of behavioral
outcomes that are situation-specific (e.g., the knowledge that behaviors on the
playground are not appropriate in the home).
Milestones in emotional development
Understanding emotions
During the toddler period, the self-conscious emotions begin to emerge and become
increasingly refined throughout the preschool period (Saarni, Campos, Camras, &
Developmental Milestones: Early and Middle Childhood
67
Witherington, 2006). Unlike the basic emotions (such as happiness, sadness, anger,
and fear), these emotions require an element of cognitive appraisal regarding one’s
intention and an understanding of social roles, and include an understanding of more
subtle emotions such as positive self-evaluation (an early form of pride) and shame.
Toddlers also develop an increased sensitivity to others in distress, which is an early
precursor to feelings of empathy which may be evident in such gestures as offering
a toy, blanket, or hug to soothe another child (Moreno, Klute, & Robinson, 2008).
Children whose parents encourage them to express and label their emotions develop
an increased emotional vocabulary and are better able to recognize emotional cues in
others (Cole, Armstrong, & Pemberton, 2010; Taumoepeau & Ruffman, 2006).
Compared to toddlers, preschoolers will use words increasingly to communicate
feelings and to comfort peers in distress (Eisenberg, Fabes, & Spinrad, 2006). However, for some children who are reactive and have poor emotion regulation, witnessing
a peer in distress can result in a contagion effect, where they become increasingly overwhelmed due to increased activation of the right central hemisphere, the part of the
brain that regulates negative emotions (Jones, Field, & Davalos, 2000). As with other
aspects of emotion regulation, caregivers can be instrumental in assisting their child
to cope with their responses to the feelings of others in ways that are sensitive and
caring, rather than fearful, angry, or punitive (Eisenberg, 2003).
Due to their enhanced cognitive capacity, school-age children increasingly associate
success with pride and failure with guilt relative to their own self-doing and selfconcept (Saarni et al., 2006). Although toddlers tend to overestimate their abilities
and underestimate task demands, school-aged children tend to take their failures
personally, and if lack of success is met with harsh criticism, they are more likely to
respond with an increased sense of shame, self-criticism, anger, and withdrawal (Mills,
2005). During this age span (six to 12 years) children are also able to increase their
understanding of ambivalent emotions; for example, understanding that a child may
be happy that the team won the game, but upset that she struck out at bat.
Emotional problem solving Chapter 6 focuses on adjustment problems in children
and adolescents which are temporary responses (such as anxiety or depression) to
environmental stressors. Towards the end of the school-aged period (around 10 years
of age) advances in cognitive development provide children with the ability to problem
solve in emotional situations. When faced with a stressor, individuals can meet the
challenge in two important ways: problem-focused coping or emotion-focused
coping. While problem-focused coping involves looking for information to help solve
a problem (e.g., “What materials do I need? Who can I get them from?”), emotionfocused coping involves the need to change how the person actually feels about the
situation or to change the reaction to the stressor (Eschenbeck, Kohlmann, & Lohaus,
2007). A child may be very upset and write her thoughts in a journal to help calm
herself down. Another way of emotional coping is to use a defense mechanism, such
as humor or rationalization.
Emotions and interpersonal aggression
Normally, aggressive outbursts, like temper tantrums, reach their peak at three years
of age; the same time that aggressive behaviors typically begin to decline. Initially,
aggression takes the form of instrumental aggression, where a toddler will push
a child to gain access to a desired object or activity (Sammy pushes Joey off the
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tricycle because it is his turn to ride). More serious forms of aggression involve hostile
aggression or interpersonal aggression where the intent is to injure another. The
research predicts that children who remain aggressive after the toddler stage, or who
increase their aggressive behaviors, have increasingly poor outcomes across a number
of areas (Loeber, Green, Lahey, Frick, & McBurnett, 2000; Patterson & Yoerger,
2002). Growing emphasis has been placed on the types of aggressive behaviors that can
be exhibited. Some children primarily demonstrate patterns of reactive aggression,
also known as “hot-blooded aggression”; these children lack emotional and behavioral
self-control (emotion dysregulation) and respond to frustration internally by high
levels of activation of their autonomic nervous system (the “flight or flight response”).
On the other hand, some children are more prone to patterns of proactive aggression,
also known as “cold-blooded aggression”; these children participate in planned acts
of aggression, such as bullying, domination, or teasing, without demonstrating any
emotional response. About half of aggressive children vacillate between the two forms
of aggression. However, about one-third will be primarily reactive, while only 15%
will engage exclusively in proactive forms of aggression (Dodge, Lochman, Harnish,
Bates, & Pettit, 1997).
Several factors have been implicated in placing children at risk for developing aggressive behaviors (biological factors, cognitive factors, social learning, and parenting practices). Increased levels of the hormone testosterone (Dabbs & Morris, 1990) and
having a parent with anti-social personality disorder have been suggested as potential biological markers for increased aggressive responses (APA, 2000). Females who
are aggressive have tendencies to engage in relational aggression often including
emotions of jealousy, betrayal, and conflict (Werner & Crick, 2004) with the goal
of damaging another girl’s “social status” or increasing “feelings of exclusion” for
the target of the aggression (Keenan, Coyne, & Lahey, 2008). Children who come
from an abusive home, or who experience harsh parenting practices, are more likely
to demonstrate reactive forms of aggression, although this can also trigger patterns
of proactive aggression (Vitaro, Barker, Boivin, Brendgen, & Tremblay, 2006). It is
possible that for some children growing up in a harsh and punitive environment causes
excess activation of the autonomic nervous system (resulting in reactive aggression),
while for others, modeling these punitive and aggressive behaviors may result in patterns of proactive aggression. The different forms of aggression will be discussed at
greater length in Chapter 9.
Milestones in psychosocial development
Understanding others and social exchange
Social referencing In situations of ambiguity, toddlers as young as 12 months will
look to the caregiver for clues to guide their behavior, a condition referred to as social
referencing (Moses, Baldwin, Rosicky, & Tidball, 2001). Studies have demonstrated
that shortly after their first birthday, children will approach or avoid an ambiguous
toy based on their mother’s facial expressions. Furthermore, the tendency to look to
others to endorse or avoid ambiguous situations or toys increases significantly between
one and two years of age (Emde, 1992).
Early social exchange Although Piaget believed that the preoperational child was
unable to take the perspective of another, Repacholi (1998) found that after observing
Developmental Milestones: Early and Middle Childhood
69
an experimenter’s dislike for crackers (disgusted expression) versus broccoli (pleased
expression), toddlers as young as 18–19 months offered the preferred food. Also by
two years of age, toddlers have a basic understanding of the rules of social exchange
in such games as hide and seek. Social exchange or affective sharing (Emde, 1992)
in toddlers is evident as they share their experiences with adults (pointing, bringing
the object to the adult). Children with autism spectrum disorders do not engage in
affective exchange due to deficits in social reciprocity and social pragmatics. The impact
of this lack of reciprocity on development will be discussed at length in Chapter 7.
Social competence During early childhood, relations with peers take on increasing
importance, since the majority of children are enrolled in school programs. Peer group
experiences can have a positive or negative effect on the development of self-concept
and social competence (the ability to engage and respond in peer interactions that are
positive). Children who are socially competent are better liked and more popular than
children who act aggressively or display negative emotions (Arsenio, Cooperman, &
Lover, 2000).
Bandura (1985) demonstrated the power of observational learning and modeling on
subsequent aggressive behaviors in children, while Coie and Dodge (1998) applied
social information processing to children’s aggressive responses and suggested that
some children are prone to misinterpret ambivalent cues (such as facial and physical
expressions) in others as “hostile” and respond aggressively as a result, a concept
referred to as the hostile attribution bias.
Children who act out or those who are withdrawn can benefit from interventions to increase positive interactions with others. Discussions of specific intervention
programs will be addressed throughout this book as they relate to specific types of
problems children may encounter when relating to their peers. Children who have
successful peer relationships do better academically than those who struggle socially
due to poor self-regulation and lack of social skills (Ladd, Buhs, & Seid, 2000). Children who are successful in conflict resolution demonstrate good ability to process
social information and social problem-solving skills, evident in their ability to: read
social cues appropriately; formulate a plan; respond; and monitor the reactions of
others (Coie & Dodge, 1998). Children with poor social problem-solving skills may
misread a social situation and commit a number of social blunders, such as attempting to gain entry to a peer group activity at a totally inappropriate time and being
rejected as a result. Other equally ineffective strategies (avoidance of social situations, aggressive reactions) serve to alienate the child even further (Dodge, Coie, &
Lynam, 2006).
Researchers can use a technique called a sociogram to determine a child’s status
among his or her peers (Asher & Wheeler, 1985). Children’s responses to a number
of questions about their classmates (Who would you invite to your party? Who would
you not invite? Who is the most popular?) can provide insight into the social dynamics
of the classroom. Researchers have isolated five potential categories: popular, rejected,
neglected, average, and controversial. Studies have shown that acceptance or rejection
by peers can have a number of positive or negative consequences. Dodge et al. (2006)
have identified two types of rejected children: rejected–aggressive (who are often
involved in conflict, aggressive, impulsive, have poor ability to interpret social cues,
and frequently use the hostile attribution bias); and rejected–withdrawn (who avoid
interactions with peers, and display anxious fears of being victimized). Eventually,
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the rejected–aggressive child often takes on the role of bully, while the rejected–
withdrawn type is more likely to become the victim (Putallaz et al., 2007). Children
who are rejected and withdrawn often also demonstrate poor academic progress,
which can have long-term consequences (Buhs & Ladd, 2001; Veronneau, Vitaro,
Brendgen, Dishion, & Tremblay, 2010). Buhs, Ladd, and Herald (2006) tracked
children from kindergarten through fifth grade and found that early peer rejection led
to poor classroom participation, and school avoidance. Later on, rejection took the
form of peer exclusion or chronic peer abuse, resulting in direct verbal or physical, or
indirect (relational), victimization.
Children who are controversial display both positive and negative behaviors and
can be confusing for peers who are drawn to them but fear them at the same time.
Although it was once thought that neglected children would suffer dire consequences
of being ignored by their peers, research has shown that these children tend to retreat
from the social arena, are shy, and tend to do well academically. Neglected children
have low social impact scores (low on social visibility).
Social skills training programs can enhance social problem solving through direct
instruction and practice in working through different social scenarios. A number
of these programs will be discussed in future chapters, as they relate to children
with specific learning disabilities (Chapter 8), and children with behavior problems
(Chapter 9).
Attachment, parenting style, and child outcomes
The attachment process
Theories of attachment and attachment styles were introduced in Chapter 2. Recall that
Ainsworth, Blehar, Waters, and Wall (1978) conducted the strange situation experiments and found patterns of secure attachment (60%), and two variants of insecure
attachment, namely: anxious–avoidant attachment (20%) (the child ignores the
mother’s departure and ignores her return); and anxious–resistant or ambivalent
attachment (10–15%) (the child is upset at the mother leaving, but is unable to
be consoled upon her return). Main and Solomon (1990) found a disorganized–
disoriented attachment pattern in their study of abused infants who displayed a
number of confused and contradictory behaviors (rocking, appearing dazed). These
disorganized responses continue during the first two years of life (Barnett, Ganiban,
& Cicchetti, 1999) and have been associated with increased risk for hostility and
aggression in the preschool and primary school years (Lyons-Ruth, 1996).
Child outcomes associated with attachment patterns Research has linked attachment
patterns to socio-economic status (SES), finding securely attached and stable patterns
in middle-SES families, with greater risk for insecure and shifting patterns of insecurity
in low-SES families (Vondra, Hommerding, & Shaw, 1999). Although longitudinal
studies have produced mixed results (Thompson et al., 2000), some studies have
found that preschool teachers rated children who were “securely attached” as higher
in self-esteem, social skills, and popularity than their insecurely attached peers (Elicker,
Englund, & Sroufe, 1992). At 10 years of age, camp counselors rated children as
more socially competent if they were securely attached as infants (Shulman, Elicker,
& Sroufe, 1994).
Developmental Milestones: Early and Middle Childhood
71
Can early attachment patterns influence later outcomes?
There is research support for Bowlby’s thesis of individual differences in the
security of the attachment process and the development of internal working
models. Not only are attachment patterns stable over time (Weinfield, Whaley,
& Egeland, 1999), but patterns can predict future outcomes, such as enthusiasm
in solving problems, peer relations, and self-esteem (Sroufe, 2002).
Studies of cross-cultural attachment patterns have found that when asked to rate
characteristics of the securely attached child and the ideal child, experts and mothers
produced very similar ratings for these two classifications, regardless of whether the
raters were from collectivistic or individualistic countries (Posada et al., 1995).
Amidst the controversy of whether a secure attachment represents the universal
ideal, Crittenden (2000) suggests that the terms “secure” and “insecure” may not be
the best ways to categorize attachment patterns when taking different contexts into
consideration. Instead Crittenden contends that terms such as “adaptive” and “maladaptive” might be more appropriate when describing different attachment patterns,
especially within the context of different cultures.
Attachment and culture
Although secure attachment is considered the gold standard in most countries,
some cultures prefer to promote different attachment styles in their children.
German mothers promote avoidant attachment as the ideal, since it instills early
independence (Grossmann, Grossmann, Spangler, Suess, & Unzer, 1985), while
Japanese children demonstrate high rates of anxious ambivalent attachment,
fostering a strong sense of dependence in this collectivist society (Miyake, Chen,
& Campos, 1985).
Attachment and intervention
Until recently, the majority of intervention programs for child issues of attachment and
maltreatment have targeted changes in the caregiver’s attitude and parenting behaviors
(Cicchetti & Valentino, 2006; MacMillan et al., 2009). Many of these programs have
delivered services as home visitations from nurses (Olds, Sadler, & Kitzman, 2007),
and other health care professionals (Dozier et al., 2006), offered on a short-term (one
to four months) or long-term basis (five months to a year).
Bakermans-Kranenburg, vanIJzendoorn, and Juffer (2003) successfully helped
mothers to modify their behavior using video feedback from taped sessions, which
increased their consistency and warmth in later sessions. Longer-term programs reveal
that long-lasting improvements can be made in maternal sensitivity, warmth, infant
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mental development, and reduced risk for future child behavior problems (Olds et al.,
1997, 2007).
Moss et al. (2011) evaluated the efficacy of a short-term (eight-week) home-visiting
program in enhancing maternal sensitivity, child attachment, and reducing child
behavioral concerns in maltreated children. The study involved 67 caregivers reported
for maltreatment and their children, randomly assigned to the intervention or control group. Intervention involved eight, weekly 90-minute visits conducted by clinical
workers who engaged the parent in a sequence of activities, involving: discussion of
the problem for that week (20 minutes); videotaping of parent–child interaction (10
to 15 minutes); video feedback session (20 minutes); and wrap-up session (10 to 15
minutes). Attachment was measured using the strange situation procedure (Ainsworth
et al., 1978) for infants up to two years of age, and the Preschool Separation–Reunion
Procedure (Cassidy, Marvin, & the MacArthur Working Group on Attachment, as
cited in Moss et al., 2011) for children two to six years of age. Results revealed
that significantly more children in the intervention group moved to the secure and
organized categories on post-test than the control group. This study demonstrates
the effectiveness of intervention in changing attachment security and organization in
older, preschool children and infants, and the success of video feedback in assisting
parents to be more sensitive to their child’s behaviors, and in enhancing their ability
to read social and emotional cues related to anxiety and insecurity.
Since maltreated children tend to exhibit more problems in the preschool period,
Moss et al. (2011) suggest that intervention during this period may assist maltreated
children to increase their ability to regulate their emotions in periods of distress,
and reduce emotional dysregulation which has been associated with increased risk for
internalizing and externalizing behaviors (Toth, Cicchetti, & Kim, 2002). Issues of
maltreatment are discussed at length in Chapter 12.
Parenting style and child outcomes
Baumrind’s four parenting styles and child outcomes Baumrind (1991, 2005) investigated parenting styles relative to the degree and nature of parent warmth/acceptance
(responsiveness), or control/monitoring (demandingness), and found four different
parenting styles: authoritative (high in responsiveness and demandingness); authoritarian (low in responsiveness, high in demandingness); permissive (high in responsiveness, low in demandingness); and uninvolved (how in responsiveness and demandingness). Initially, it was thought that the authoritative style was the universal “gold
standard” for parenting style because it was associated with the most positive outcomes
for children (see Chapter 2 for more background information on parenting styles).
Is the authoritative parenting style a universal
gold standard?
Studies have found that the harsh discipline associated with the authoritarian
parenting style may be of benefit in some situations, such as environments where
there are increased opportunities for youth to engage in high-risk behaviors in
dangerous neighborhoods (Bradley, 1998; Kelley, Power, & Wimbush, 1992).
Developmental Milestones: Early and Middle Childhood
73
However, other researchers suggest that punitive practices may signal acceptance
of violence and encourage youth to model these behaviors (Raymond, Jones, &
Cook, 1998).
Authoritative style The authoritative style fosters many child qualities, including:
increased self-control, positive mood and self-esteem, task persistence, social competence, and academic performance (Herman, Dornbusch, Herron, & Herting, 1997;
Luster & McAdoo, 1996). In middle childhood, school-age children raised by authoritative parents tend to score higher in agency (the tendency to take initiative) and
self-assertion (Baumrind, 1989).
Authoritarian style Parents who employ an authoritarian style tend to use harsh
coercive practices and demonstrate minimal warmth. Children raised in this manner
are more likely to be anxious and unhappy, and to have low frustration tolerance, and
can be passive aggressive (Baumrind, 1991). Boys tend to be aggressive with peers,
while girls may be overly dependent and easily overwhelmed (Hart et al., 2000).
Permissive style Lacking in guidance, children raised in permissive and indulgent
households tend to be impulsive, lacking in self-reliance, and demanding, with boys
at risk for dependence and low achievement (Barber & Olsen, 1997).
Uninvolved style In its extreme form, uninvolved parents can be guilty of child
neglect, with far-reaching negative consequences for development in cognitive, social,
and emotional areas. Children raised by indifferent parents tend to be dependent and
moody with minimal self-control or social skills. The majority of uninvolved parents
are emotionally unavailable to their children due to life stressors (Maccoby & Martin,
1983).
Child outcomes for parenting styles are summarized in Table 3.4.
Culture, SES, and parenting styles
Parenting styles and culture Parenting styles may also reflect different cultural
expectations. Joshi and MacLean (1997) compared maternal expectations for child
development for 45 tasks, in mothers from India, Japan, and England. Japanese mothers demonstrated higher expectations than British mothers in areas of education, selfcare, and environmental independence, while Indian mothers had lower expectations
than Japanese and British mothers in all areas except environmental independence.
Su and Hynie (2011) evaluated the effects of life stress, social support, cultural
beliefs, and social norms on parenting style for mothers of preschool children two to
six years of age, for mainland Chinese (MC), European Chinese (EC), and Chinese
Canadian (CC) mothers. Results revealed that the mothers’ level of stress moderated
parenting style, with mothers being more authoritative when less stressed and when
their parenting beliefs were less traditional (i.e., more individualistic). In this study, the
use of an authoritarian parenting style increased, especially for CC and MC mothers,
74
Table 3.4
Clinical and Educational Child Psychology
Parenting style and child outcomes
Child
independence
Parenting style
Child outcomes
Child autonomy
Authoritative
Good self-concept and
self-esteem
Task persistence
Higher academic
performance
Higher agency
Fearful, anxious, and
unhappy
Low frustration
tolerance
Boys: aggressive
Girls: dependent
Demanding
Few boundaries
Low self-reliance
Boys: dependent, low
achievement
Dependent
Moody
Unpredictable based on
nature of “acquired”
role models
Low self-control
Poor social skills
Child is able to
negotiate and make
decisions within
appropriate limits
Independent
Minimal opportunity for
autonomy
Parent makes the
decisions with
minimal or no input
from child
Permissive and
indulgent
Child makes decisions
without guidance or
direction
Parents are indifferent to
child’s concerns or
issues
Lack of
independence
Authoritarian
Permissive–
indulgent
Permissive–
uninvolved
Excessive
independence
Indulged
Indifferent
when they were under the most stress. Sumer, Orta, and Ankara (2010) conducted a
meta-analysis of 34 studies conducted in Turkey regarding parenting style and child
outcomes. Based on their results, studies consistently endorsed the authoritative parenting style, versus the authoritarian parenting style, for producing the most positive
outcomes in areas of increased self-esteem, less aggressiveness, academic success, lower
anxiety, and higher self-acceptance.
Parenting styles and SES Although children develop behavioral problems through
the interaction of multiple influences, low family SES has long been acknowledged as
a risk factor for many child and adolescent problems, including: behavior, academic,
and social problems (Dodge, Pettit, & Bates, 1994). Parenting styles that are more
negative (Grant et al., 2003) have been associated with lower levels of SES and
higher levels of child problems. However, as Callahan and Eyberg (2010) report, the
importance of maternal education is often not included in studies of low SES and as a
result valuable information has been lost, since in their study higher levels of maternal
education were associated with increased maternal warmth and responsiveness. In their
studies, the inclusion of factors such as maternal income, education, and occupation
provided much more predictable indicators of higher maternal prosocial verbalizations
and potential resources for child resiliency in these low SES populations.
Developmental Milestones: Early and Middle Childhood
75
Parenting practices, parenting styles, and child outcomes In addition to parenting
styles, researchers have also studied the impact of various parenting practices on a
number of child outcomes, including school achievement, child behavior, and behavior problems, as well as the mediational links between parenting styles and SES, as
was discussed. While parenting practices refer to the goals parents set for “socializing”
their children based on their expectations and beliefs, parenting style is related more
to the prevailing “attitude and climate” embedded in the manner in which parents
achieve these goals (Darling & Steinberg, 1993).
School achievement Positive relationships have been found between parenting practices, such as parental engagement, expectations, and beliefs, and children’s academic
outcomes (Bronstein, Ginsburg, & Herrera, 2005; Davis-Kean, 2005; Spera, Wentzel,
& Matto, 2009). In a meta-analysis of the influence of parenting practices on children’s academic success, Jeynes (2010) reported that parental expectation was the
single leading contributor to academic achievement for both elementary school and
secondary school students. With respect to parenting style, the authoritative style
(high in responsiveness, high in demandingness/monitoring) was significantly related
to elementary and secondary school achievement; however, while responsiveness consistently was related in a positive way, monitoring (e.g., checking homework) was
not significantly related to achievement for either elementary or secondary school
students (Jeynes, 2010). As a result of this analysis, Jeynes (2010) has recommended
that educational programs aimed at enhancing parental involvement focus more on
the subtle factors such as encouragement and communication, rather than tasks such
as monitoring of homework and attending school functions.
Based on a large sample from Statistics Canada, Areepattamannil (2010) surveyed
over 6,000 households regarding school achievement (parents’ reports of school
grades), parenting style (encouragement and monitoring), parenting practices (expectations and beliefs), and family SES. Results of this study were consistent with results
from previous research and indicated that children from families higher in SES had
higher educational achievement scores, and that both components of the authoritative
parenting style (responsiveness and demandingness/monitoring) were significantly
related to academic achievement, but not in the expected direction for monitoring.
While responsiveness and encouragement were related to academic success in a significant and positive direction, as parental monitoring increased academic achievement
decreased. The latter result supports findings of other researchers (Niggli et al., and
Rogers et al., as cited in Areepattamannil, 2010) who reason that excessive monitoring
of academic activities in the form of checking homework, monitoring time, and setting rules may actually increase academic pressure, lower academic self-concept, and
result in weaker achievement. As a result, “parental monitoring in the form of parental
pressure and control can decrease children’s intrinsic motivation and may undermine
the learning process and children’s sense of personal value and responsibility” (Areepattamannil, 2010, p. 287).
Given that parental beliefs and encouragement can have a strong impact on a child’s
academic success, there is a need for educators to enhance parental engagement in
their child’s academic orientation. One of the most successful parental involvement
programs in the United Kingdom (Sure Start) has been successful in enhancing parent
involvement through home visitations which are an integral part of the program
(Garbers, Tunstill, Allnock, & Akhurst, 2006).
76
Clinical and Educational Child Psychology
Social and emotional development In the previous discussions regarding attachment, it was apparent that the parent-child relationship serves as a prototype for
future relationships and sets the stage for the nature of increasing socialization. It is
not surprising to see that researchers such as Baumrind (1991, 2005) have found that
parenting styles have a direct impact on child development in many areas, including
social and emotional development. However, while most studies have focused on
maternal responses, or combined maternal and paternal responses, Rinaldi and Howe
(2012) examined the separate roles of mothers’ and fathers’ parenting styles on child
behavior patterns in toddlers. Results revealed that fathers’ authoritarian parenting
style (use of physical coercion, verbal hostility, and lack of reasoning with children)
predicted externalizing and internalizing problems in the toddlers, while mothers’ permissive parenting style predicted externalizing behaviors. The authoritative parenting
style for all parents predicted the most adaptive behaviors.
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4
Developmental Milestones:
Adolescence
Chapter preview and learning objectives
Adolescent milestones: an introduction
Neurological and physical development
Brain development
Self-regulation, risky choices, and sensation seeking
Physical maturation
Physical development and gender
Gender, culture, and the onset of puberty
Gender, culture, and body dissatisfaction
Cognitive and social development
Cognitive milestones
Piaget: the period of formal operations
Information processing
Social cognition
Adolescent egocentrism
Moral reasoning
Identity, self-concept, and awareness of others
Identity and self-concept
Awareness of others and social relationships
Attachment and adolescent outcomes
Secure attachment
Parenting styles and adolescent outcomes
References
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Chapter preview and learning objectives
Prior to the publication of Adolescence (Hall, 1904), few researchers had focused on
the period of development marking the transition from childhood to adulthood. Hall
(1904) depicted adolescence as a period of Sturm und Drang (storm and stress) due
to significant changes occurring in physical growth (spurts), sexual maturity (hormonal changes), and emotional development. Today we know that only a minority of
Clinical and Educational Child Psychology, First Edition. Linda Wilmshurst.
© 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.
Developmental Milestones: Adolescence
85
adolescents will experience significant difficulties during these years (Arnett, 1999).
Yet adolescence does represent a period of increased risk in a number of areas, including: substance use and abuse, eating disorders, delinquent behaviors, depression, and
suicide (Cicchetti & Rogosh, 2002).
In this chapter, typical milestones will be discussed that occur in adolescence in
neurological, physical, cognitive, and social development. Cross-cultural research will
address how these milestones occur in different geographical areas, while gender
studies will provide greater insight into how males and females respond to changes
in such areas as body image and supportive friendships. Discussions will provide the
reader with a better understanding of:
r
r
r
r
r
r
r
whether adolescence is universal across all cultures;
the significant neurological changes (brain chemistry and brain function) that take
place during this period of development;
significant physical changes that accompany this period of development and the
impact of gender and culture on attitudes towards these physical changes;
cognitive advances and limitations during adolescence;
the development of a more integrated sense of social cognition and thinking about
the social world that takes places during this period;
the changes in self-concept, identity, and social relationships that evolve from the
beginning to the end of adolescence;
the impact of attachment style and parenting style on outcomes in adolescence.
This chapter provides excellent background information in preparation for better
understanding why adolescents are at increased risk for substance use/abuse and
eating disorders (Chapter 11) during this period of development.
Adolescent milestones: an introduction
Is adolescence universal? Whether or not adolescence is universal has been a matter of
debate. Prior to the industrial revolution, children often worked and married at very
young ages and often bypassed adolescence. Today, most theorists believe that the
majority of societies recognize an “adolescent period” during life span development
(Schlegel & Barry, 1991). However, “adolescence” can vary by culture, gender, and
social class, with children of lower classes in some societies working and marrying much
earlier, pre-empting the adolescent period (Saraswathi, 1999). Delaney (1995, p. 891)
suggests that adolescent rites of passage are universal and represent a cross-cultural
phenomenon that has four elements:
1.
2.
3.
4.
separation from society;
preparation or instruction from an elder;
a transition (in this case from child to adult);
a welcoming back into society with the acknowledgement of changed status.
Although Hall’s depiction of “adolescent angst” has been moderated by contemporary research, the idea that adolescence can be a difficult period of development
relates to changes evident in three broad areas: parent–youth conflict; the presence of
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mood swings (particularly depression); and tendencies to engage in high-risk behaviors
(Buchanan et al., 1990). Research has confirmed that the frequency of parent–youth
conflict peaks during early adolescence but is most intense during mid–adolescence
(Laursen, Coy, & Collins, 1998). In addition, adolescents experience significantly
more feelings of self-conscious emotions and mood disruptions compared to middle
childhood (Larson & Richards, 1994). Tendencies to engage in risky decisions and
behaviors can escalate during adolescence (Gardner & Steinberg, 2005). However,
even within these patterns, there is wide variability and individual differences in the
expression of these behaviors, as well as etiology, based on the inter-relationships
among a number of factors, including physical, neurological, and cognitive pubertal changes, and environmental factors (parenting style and practices, as well as peer
influences).
Neurological and physical development
Brain development
Prior to the 1960s, it was believed that the brain completed its development early in
adolescence. However, we now know that the prefrontal cortex continues to evolve
into young adulthood. Studies have provided increasing evidence that executive functions (such as selective attention, decision-making, and response inhibition) which are
primarily located in the prefrontal cortex, show significant development from early
to late adolescence (Brocki & Bohlin, 2004, 2006; Casey, Vauss, Chused, & Swedo,
1994). Furthermore, there is some support for the suggestion that frontal lobe circuitry
may actually decline with the onset of puberty (11 to 12 years) due to a proliferation of synapses that occur during this time, in the absence of a period of pruning
(which occurs later in adolescence), rendering performance less efficient (McGivern,
Andersen, Byrd, Mutter, & Reilly, 2002).
In early childhood, the brain is highly flexible; however, it loses plasticity in adolescence, as parts of the brain become more specialized in their functions.
Learning a second language in secondary school
or university?
Research suggests that children should start to learn a second language in
preschool or primary school. The loss of brain plasticity is most evident in studies of second-language learning which demonstrate a gradual decline in abilities
from 10 years of age, followed by a sharp drop in the acquisition rate of new
language skills from age 12–13 onward (Johnson & Newport, 1989).
Although specialization of brain function gradually evolves over the course of development, hemispheric specialization is completed around the onset of puberty. By
this time most individuals process certain activities in localized areas of the brain (e.g.,
using the right side of the brain for visual spatial information, and the left side for
Developmental Milestones: Adolescence
87
language tasks). However, while males tend to use the left side of their brain to process language-based tasks, and the right side of the brain to process emotions, females
use both sides of their brains to process language and emotions (Jaeger et al., 1998;
Skrandies, Reik, & Kunze, 1999). There is speculation that males and females are
socialized to respond in different ways. Girls may be encouraged to bring emotional
sensitivity to the problem-solving situation, while males may be programmed to bring
logic to the table and leave emotions behind (Fischer, 1993).
Self-regulation, risky choices, and sensation seeking Although there is significant
improvement in self-regulation compared to earlier stages of development, studies
using functional magnetic resonance imaging (fMRI) techniques have determined
that the integration of the prefrontal cortex with other brain areas is not as effective as in the adult brain, and adolescents lag behind adults in their ability to inhibit
responses, in planning ability, and in future orientation (Steinberg et al., 2009). The
immaturity of the prefrontal network in conjunction with heightened neural activity
and excitation during adolescence results in adolescents responding to situations with
inflated reactions, whether responding to a distressing (stressful) or pleasurable experience. The intensity of responses coupled with lack of future planning and impulsivity
may place youth at increased risk for experimenting with substances, and engaging in
high-risk behaviors such as unprotected sex or reckless driving. Adolescence is associated with heightened tendencies to take risks, resulting in statistically more accidents,
criminal activity, and suicides occurring during this period (Steinberg et al., 2008).
In addition, the sex hormones are also responsible for heightened responsiveness in
the prefrontal cortex and amygdale, which are instrumental in our recall of emotional
events and interpretation of nonverbal emotional expressions.
In their study of peer influence on risk taking and risky preferences, Gardner and
Steinberg (2005) evaluated the responses of individuals in three age groups: adolescents (13–16 years), youth (18–22 years) and adults (24 years and older) on two
questionnaires and a risk-taking task. Subjects were randomly assigned to an individual or group (of three same-aged peers) condition. The results revealed that risk
taking and risky decision-making declined with age, and that being assigned to the
group condition increased risk taking for adolescents and youth. Therefore, not only
is adolescence a time of increased vulnerability for engaging in high-risk behaviors,
this tendency can be magnified in the company of peers.
Casey, Jones, and Somerville (2011) suggest that neurobiological and cognitive
theories have not been able to account for the nonlinear changes that occur during
adolescence that make this population so vulnerable to engaging in impulsive behaviors
and making risky choices. They argue that adolescent behavior is qualitatively different
from that of childhood or adulthood. Based on the theory that cognitive control
improves with age, adolescents should be making fewer poor choices relative to their
younger peers, but research shows that risky choices and impulsive responses actually
increase during the adolescent period (Windle et al., 2008). Although adolescents
15 years of age or younger act more impulsively than older adolescents, even those
aged 16–17 years fall short of executing control equivalent to that of adults (Feld,
2008). Casey et al. (2011, p. 22) propose a neurobiological model of adolescence
that goes beyond the “exclusive association of risky behavior to the immaturity of the
prefrontal cortex,” based on their investigation of adolescent transitions in and out
of this developmental period. What they suggest is a “perfect storm” based on the
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“imbalance between a heightened sensitivity to motivational cues (mature subcortical
regions) and immature cognitive control” (prefrontal cortical control) that places the
adolescent at risk (Casey et al., 2011, p. 21, emphasis added).
While adolescents are capable of rational decision-making, and are able to articulate
inherent risks in the behaviors that they produce (Reyna & Farley, 2008), this does
not transfer to situations where they are “caught in the moment.” “In emotionally
salient situations, subcortical systems will win out (accelerator) over control systems
(brakes) given their maturity relative to the prefrontal control system,” while in less
emotional situations, the cortical control systems are not impaired (Casey et al., 2011,
p. 22). As a result, while the ability to inhibit responses improves from childhood to
adulthood in a linear progression, risk-taking or reward-seeking behaviors are at their
most pronounced in adolescence (Windle et al., 2008) with sensation seeking peaking
between 10 and 15 years of age (Steinberg et al., 2009).
Adolescent brain development has also been the focus of inquiry regarding increased
risk for alcohol and other drug problems (Bava & Tapert, 2010). It has been suggested that the dual system noted by Casey et al. (2011) may also account for reward
seeking and risky choices based on increased activation in subcortical regions of the
brain, relative to immaturity in the prefrontal cortex. In their review, Bava and Tapert
(2010) discuss the inter-relationships between brain structure and function within the
context of socio-emotional processing during adolescence, with adolescents showing heightened activation in the bottom-up emotional processing centers such as the
amygdale in the limbic system, and increased efficiency of white matter fibers, in the
presence of a slower and more protracted development of the prefrontal cortex (cognitive control). Later on in this chapter, adolescents’ tendencies to self-monitor and
their sensitivity to evaluation will be discussed; these can also be related to increased
activation of the emotional centers in the brain. Increased sensitivity, however, also
can lead to increases in behaviors to seek rewards and increased stimulation (sensation
seeking).
Neurotransmitter changes, such as increased density of dopaminergic connections
during this period, can also impact risk taking and sensation seeking (Tunbridge et al.,
2007). In addition, neurotransmitter function is also influenced by hormonal changes
(gonadotropic release of hormones in the pituitary gland) heightening sexual and
aggressive behaviors (Paus, Keshavan, & Giedd, 2008).
Because adolescents experience heightened activity in the emotional centers of their
brains, they are more likely to be influenced by emotions in their decision-making. In
addition, youth also demonstrate greater activity (ventral striatal activation) than adults
or children when they anticipate a reward (Geier, Terwilliger, Teslovich, Velanova, &
Luna, 2010) and greater dopamine release when they experience rewarding circumstances (Koepp et al., 1998). This combination may be responsible for perpetuating
engagement in a cycle of reward-driven behavior and increased vulnerability to substance use in adolescence (Bava & Tapert, 2010).
Emotions and mood Increases in sensitivity and heightened activation of the emotional centers and increases in hormone levels can all result in instabilities in adolescent
moods. Studies have demonstrated that adolescents report more dissatisfaction with
their mood states, which has been attributed to an increase in stressful life experiences
during this period, such as relationship problems, family conflicts, and problems at
school (Larson & Ham, 1993).
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Physical maturation
Physical development and gender Until 10 years of age, growth is similar in boys and
girls. Females experience a growth spurt starting around 10 years of age, with the
onset of menstruation (menarche) occurring towards the end of the growth spurt
(12 years). For males, the growth spurt occurs around 12 years of age, with sexual maturity occurring about mid-way through the fourteenth year (Tanner, 1990).
While early-maturing males seem to reap the benefits of greater athletic prowess and
popularity, early onset for females is associated with more negative outcomes, such
as increased parental conflict (Ge, Conger, & Elder, 1996, 2001), increased risk for
distress and delinquency (Dick, Rose, Viken, & Kaprio, 2000), as well as moodiness
and depressive symptoms (Mendle, Turkheimer, & Emery, 2007). Later-maturing
boys are at greater risk for insecurity and social awkwardness (Simmons, Burgeson,
Carlton-Ford, & Blyth, 1987).
Gender, culture, and the onset of puberty Adolescence marks the onset of puberty,
physical changes that occur as the primary sex characteristics (maturation of the
sex organs) and secondary sex characteristics (physical changes) reach their peak.
The pituitary gland is responsible for initiating puberty through a feedback system,
composed of the hypothalamus, pituitary gland, and gonads, that regulates levels of
sex hormones in the system. Androgens are produced by the adrenal glands. Under
certain conditions (threat, stress, or depression), the hormone cortisol is released into
the system by the adrenal glands as the hypothalamus–pituitary–adrenal (HPA)
system sends a “fight or flight” signal. As a result, psychosocial factors such as stress,
exercise, and nutrition can all influence the timing of puberty (Ellis, McFaydenKetchum, Dodge, Pettit, & Bates, 1999).
Eveleth and Tanner (1990) found that female menarche varied widely across cultures, from as early as 12 years of age (middle-class Caracas, Venezuela) to 18 years
of age (Bundi highlands of New Guinea). Historically, menarche has been declining,
with a drop of approximately 0.3 years per decade in the last 140 years. Several reasons have been suggested for this trend, including: better nutrition (leading to earlier
onset), physical exertion (higher activity levels correlate to later onset), and elevation
(high altitude regions have later onset).
Gender, culture, and body dissatisfaction In middle childhood, girls begin to accumulate fat (adiposity) in their arms, legs, and trunk in preparation for puberty (Brandao,
Lombardi, Nishida, Hauache, & Vieira, 2003). This increase in physical mass coincides with increased body dissatisfaction among girls (Stice & Whitenton, 2002),
and distress due to a lack of success in dieting (Nowak, 1998).
Research in the 1990s focused on Caucasian upper middle-class women from
Western countries and found that 90% of white American teens were dissatisfied
with their weight compared to 70% of their African American peers (Parker, Nichter,
Vuckovic, Sims, & Ritenbaugh, 1995). Recently, studies have found African American
and white American females at comparable risk for eating disorders (Walcott, Pratt,
& Patel, 2003; Mulholland & Minz, 2001). Body dissatisfaction and eating disorders
appear to be on the increase among Asian American women and among females in
many Asian countries (Walcott et al., 2003).
The media message of the Anglo-European beauty ideal has reached worldwide
audiences and there is a growing trend for females from ethnic minorities and
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non-Western cultures to adopt Western images of “beauty” in lieu of their own
ethnocultural values (Harris & Kuba, 1997).
Tiggemann and Pickering (1996) suggest a strong link between the media, gender
role identity, body stereotype, and body dissatisfaction. The authors found that adolescents who watched more television (especially movies and soap operas) expressed
more dissatisfaction with their bodies.
Fiji: before and after the advent of television
Since television was introduced in 1995, eating disorders have increased fivefold
among adolescent girls in Fiji. Prior to this time, only 3% of the Fijian teens
reported that they had induced vomiting to lose weight, but by 1998, the
rate rose to 15%. After viewing American, Australian, and British actresses on
television, 62% reported dieting and 74% said they felt fat and wanted to look
more like the actresses (Becker, Burwell, Herzog, Hamburg, & Gilman, 2002).
Males entering puberty experience a decrease in fat and an increase in muscle
strength. Although male rates for body dissatisfaction lag behind females, there has
been increasing body dissatisfaction among males in the past 15 years (Youth Risk
Behavior Survey; CDC, 2005). Disorders of body image, such as body dysmorphic disorder, once considered rare, are currently evident in 1–2% of Western males
(Phillips, 1996). A specific form of the disorder, muscle dysmorphia (a preoccupation with muscularity), sometimes referred to as the “Adonis complex,” is increasingly
found in Western males (Pope, Gruber, Choi, Olivardia, & Phillips, 1997; Pope,
Phillips, & Olivardia, 2000b).
Body dysmorphic disorder (BDD)
BDD, also known as dysmorphophobia, causes significant distress due to the
perception that some aspect of the appearance is flawed or defective. Onset is
often in adolescence. One study found that 30% of those diagnosed with BDD
became housebound, while 17% had attempted suicide (Phillips, McElroy, Keck,
Pope, & Hudson, 1993).
Abuse of anabolic-androgenic steroids and other “body image drugs” can be
a serious consequence of body image dissatisfaction in males (Blouin & Goldfield,
1995; Kanayama, Pope, & Hudson, 2001); a condition that has been described as
the “flip side” of anorexia (Smith, 1997). Anabolic steroid abuse has become a major
public health concern in the United States, Europe, and Australia (Kindlundh, Isacson,
Berglund, & Nyberg, 1999; Kanayama, Pope, Cohane, & Hudson, 2003), although
it appears to be rare in non-Western societies (Yang, Gray, & Pope, 2005).
Pope et al. (2000a) conducted male body image studies in the United States,
France, and Austria, and found that all males selected an ideal body image that was
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about 28 pounds (13 kilograms) more muscular than their own physique. Males also
overestimated female attraction to an image in excess of their ideal (30 pounds/14
kilograms), although in reality, females selected images closer to the average male.
Media influence on body dissatisfaction in males has rarely been studied (HesseBiber, Leavy, Quinn, & Zoino, 2006). Pope, Olivardia, Borowiecki, and Cohane
(2001) found increasing inclusion of male pictures (from 3% in the 1950s to 35%
in the 1990s) in magazines in various states of undress (less clothing than would
normally be worn on the street), compared to an increase of only 20% in female
pictures, suggesting an increased focus on male body image in the media.
Cognitive and social development
Cognitive milestones
Piaget: the period of formal operations Piaget called this stage of reasoning the period
of formal operations to emphasize advances in problem solving, logical thinking,
and the ability to combine statements into propositions. A major advance occurs in
the adolescent’s ability to use abstract reasoning to solve hypothetical problems, or
hypothetico-deductive reasoning.
Although skills at this level build on earlier skill sets, they are qualitatively different
from previous abilities. Inhelder and Piaget (1958) developed a series of experiments
to test the acquisition of formal operational skills in adolescents. Their most famous
experiment was the pendulum problem. In this task, adolescents are given a number
of weights that can be tied to a pendulum with string. To derive a solution to the
problem, they must rule out weight, height of release, and force of push, to determine
that length of string is the factor that makes the difference. Adolescents use a systematic
approach to solve the problem, while younger children approached the task randomly.
Information processing Selective attention (ability to ignore distracters), divided
attention (ability to multitask), short-term memory, long-term memory, and
metamemory (knowledge of memory strategies) all improve in adolescence (Flavell,
Miller, & Miller, 2002). Advances in metamemory result from the understanding that
various strategies or mnemonics (such as taking notes, highlighting important parts
of documents) can assist in managing information (Flavell et al., 2002). Efficiency in
accessing information (automatization) is also less effortful at this stage (Case, 1998).
Social cognition
Social cognition involves how we think about our social world and how these perceptions influence our behaviors. The immediate environment (friends, family, teachers,
neighborhood) can have a powerful impact on our thoughts and behaviors, while the
consequences of more distal influences (economic conditions, culture) may be more
subtle. The influence of the media on shaping impressionable attitudes towards body
shape and substance use during adolescence has been well documented in research.
Adolescent egocentrism The preschool child views the world from an egocentric perspective because of an inability to take the perspective of another. In adolescence, the
ability to think about thinking (metacognition) and consider abstract and hypothetical situations can produce a self-conscious framework for analysis. In addition, as was
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previously discussed, adolescents are highly sensitive to emotional information due to
heightened brain activity in the subcortical regions relative to immaturity in the prefrontal cortex. Within this context, adolescent egocentrism can result from excessive
self-reflection and a preoccupation that they are the focus of everyone’s attention.
Two important concepts are fundamental to adolescent egocentrism: imaginary
audience and personal fable (Elkind, 1967; Elkind & Bowen, 1979). The imaginary
audience reflects adolescents’ concern that everyone is looking at them, which may
cause them to retreat into their own private world, or perform for the audience (talking
loudly, wearing dramatic clothing, and so on). The personal fable is adolescents’
belief in their own invulnerability, omnipotence, and personal uniqueness, which
supports tendencies to engage in high-risk and reckless behaviors during this period
of development.
Eventually, sharing experiences with peers often enhances the understanding that
others share similar feelings and concerns. However, adolescents who are isolated
from peers may continue to harbor fears of being scrutinized and criticized by others,
as well as increased feelings of being misunderstood.
Moral reasoning
Piaget For Piaget, moral reasoning evolves over the course of two broad developmental stages, heteronomous morality or moral realism, which was discussed in the
previous chapter, and autonomous morality, a transition that occurs in late childhood and adolescence as youth begin to understand that rules can change if there is
agreement among those involved.
Kohlberg’s stages of moral understanding Kohlberg’s (1976) theories of moral
development were also introduced in the previous chapter, and represent six stages
of moral understanding across the lifespan, although there are three predominant
categories. The stages reflect responses to a series of moral dilemmas, vignettes
in which an individual is faced with a moral choice. In one scenario, the “Heinz
dilemma,” Heinz tries desperately to acquire enough money to buy medicine for
his dying wife. When unsuccessful, Heinz steals the drug. Kohlberg’s level of moral
reasoning would be based on a response to the question: Should Heinz have done that?
Why? Kohlberg’s six stages of moral development are available in Table 4.1
Table 4.1
Kohlberg’s stages of moral understanding
Morality
Stages/orientation
Motivation
Preconventional
morality
Stage 1: Obedience and
punishment
Stage 2: Instrumental and
hedonistic (reward and benefit)
Stage 3: Good boy; nice girl
Stage 4: Authority or law and order
Stage 5: Social contract
Stage 6: Hierarchy of principles;
universal ethical principles
Good behavior is based on
avoiding punishment
Good behavior results in obtaining
a reward
Approval of the group
Sense of duty; do the right thing
Self-respect and respect for rights
of others
Act in accordance with one’s own
set of principles (conscience)
Conventional
morality
Postconventional
morality, or
principled
morality
Developmental Milestones: Adolescence
93
Kohlberg believed that preconventional morality was evident until nine or 10 years
of age, and that the majority of adolescents and adults function at the conventional
level.
Longitudinal studies have supported the order of Kohlberg’s stages, with stage
3 reasoning peaking during mid-adolescence, and stage 4 morality continuing to
develop into young adulthood (Dawson, 2002). The final stage of morality, postconventional morality, was reserved for individuals who endorsed those principles that
went above and beyond those prescribed by convention, such as a journalist serving
a jail sentence for not divulging a source of information, or women involved in the
suffragette movement who chained themselves to railings in order to secure voting
rights. Apparently, only about 5% of the population would meet this level of morality
(Colby, Kohlberg, & Liberman, 1984).
Gender, culture, and morality Gilligan (1982) has argued that Kohlberg’s model
is biased towards the male ideal, since female actions based on affiliation (caring) are
rated lower on the hierarchy (stage 3) than actions motivated by duty and justice
(stage 4). There is mixed support for Gilligan’s claims: themes of justice and caring
are evident in responses from both genders (Jadack, Hyde, Moore, & Keller, 1995);
however, themes of caring are more prevalent among females (Wark & Krebs, 2000).
Although the sequence of Kohlberg’s stages seems to be universal (Snarey, 1995),
children and youth in industrialized nations pass through the stages in an accelerated
fashion relative to peers in non-industrialized nations (Miller, 1997). In cultures where
society is predominant at an early age (e.g., Israeli kibbutzim, which are small, closely
knit societies), children reach more advanced levels and adolescents often reach stages
4 and 5 (Snarey, Reimer, & Kohlberg, 1985).
A major criticism of Kohlberg’s model is that at the highest levels, morality is based
on “individual principles and conscience, regardless of the societal laws or cultural
customs,” which reflects a bias towards individualistic versus collectivistic societies
(Matsumoto & Juang, 2008, p. 103).
Collectivistic societies
In collectivistic societies (more traditional cultures), the well-being of the
group takes precedence over the individual. Loyalty and respect for the group
(family, elders, society) are among the highest ideals in such a culture, which
would only be seen as level 3 morality in Kohlberg’s model.
Identity, self-concept, and awareness of others
Erikson believed the major life task facing adolescents was to emerge from this stage of
development with a sense of identity; youth who do not master this task face young
adulthood unprepared, in a state of identity confusion.
Identity and self-concept Early in adolescence, youth consolidate similar personality
traits into more global concepts (e.g., being a good singer and artist may be clustered
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into the concept of being “talented”). However, self–reflection may also point out
inconsistencies that may be difficult to reconcile (e.g., I am fun to be with, but I am also
moody sometimes and want to be alone.) At this stage, self-descriptions take on more
abstract and complex attributes (In some areas I can be very conservative, but in others
I can be very liberal). Ultimately, the ability to see various sides of the self promotes
better understanding of individual strengths and weaknesses (e.g., I excel at math, but
do poorly in composition).
As autonomy increases and dependence on adults declines, adolescents rely increasingly on peers and close friends for information and support. Sharing of information
with peers affords the opportunity to compare themselves to others, an integral part
of identity formation. Throughout adolescence, social relationships evolve to take
on more mature characteristics such as intimacy, mutual understanding, and loyalty
(Collins & Madsen, 2006). In addition, increased self-disclosure provides a greater
understanding of the complexity involved in relationships and the need to be sensitive
to others’ needs, preparing the adolescent for romantic partnerships in the future (De
Goede, Branje, & Meeus, 2009).
Is there such a thing as too much self-esteem?
In their extensive review of research on aggression, Baumeister, Smart, and
Boden (1996) found high self-esteem was often related to violence and aggression. Perpetrators of violence can have an inflated sense of self, despite failures at
school and in personal relationships. When challenged, these individuals retaliate with anger and aggression, rather than suffer the consequences of loss of
self-regard.
Identity status Marcia (1980) suggests that identity formation in adolescence can
take one of four possible directions based on the degree to which the adolescent
engages in exploring the available options and their commitment to their role or
identity. The four identity statuses are outlined in Table 4.2.
Table 4.2
Identity formation and identity status
Identity status
Exploration
Commitment
Identity
achievement
Moratorium
Identity foreclosure
Alternatives have been explored
and a decision has been made
In the information gathering
stage
No exploration of alternatives
Identity diffusion
No exploration of alternatives
Commitment to a definite
course of action
Not ready for commitment (on
hold)
Committed to a pre-selected
path selected by others
(parents, teachers)
Not committed to any course of
action
Developmental Milestones: Adolescence
95
Adolescents with identity achievement (exploration and commitment) have the
highest levels of self-esteem, are more goal-oriented, and tend to enroll in the most
demanding college majors. Individuals with identity diffusion (no exploration or
commitment) have the lowest self-esteem, and experience the most academic and
social difficulties. Adolescents in foreclosure (no exploration, but committed) experience the lowest levels of anxiety, while those in moratorium (on-going exploration,
no commitment) have the highest levels of anxiety (Berzonsky & Kuk, 2000; Kroger,
2000).
The generation gap?
Does the gap between adolescents and parents widen as a result of increasing
autonomy and time spent with peers? Although arguments between parents and
teens are common on issues of personal choice (such as dress code), parent
and teen attitudes are very similar regarding fundamental values, such as social,
religious, and political views (Chira, 1994).
Research has also investigated the role of identity formation on mental health and
well- being. Youth develop a better sense of selfhood, identity, and cohesion when they
shift from a status of diffusion or foreclosure towards taking on more responsibility,
evident in moratorium or identity achievement (Snarey & Bell, 2003). Although, as
noted earlier, those in moratorium may be more anxious, they are also driven to reduce
their anxieties by gathering more information prior to decision-making, which can be
an adaptive response in times of uncertainty and result in better problem solving
through critical evaluation of alternatives (Berzonsky, 2003). As a result, those in
moratorium often transition to a state of identity achievement.
Youth who are in states of foreclosure or diffusion do not fare as well as their peers in
moratorium or identity achievement. In contrast to peers who seek out information to
help with problem solving for dilemmas, these youth are more passive and either opt
to conform to rigid expectations and beliefs espoused by parents (foreclosure), or opt
out of the process entirely, avoiding decision-making (diffusion) and taking a “wait
and see” attitude (Berzonsky & Kuk, 2000). Youth who adopt a diffuse-avoidant style
are at the highest risk for drug abuse and antisocial behaviors, which may also place
them at increased risk for a sense of hopelessness and depression (Schwartz, Cote, &
Arnett, 2005).
Awareness of others and social relationships Self-understanding paves the way for
greater understanding of others. Selman’s (1980) seminal work on relationships reveals
that our cognitive level dictates how we conceptualize relationships. The adolescent
is often painfully aware of how others think and feel and may shrink from being
overwhelmed by over-sensitivity to others. In late adolescence, a sense of mutual
understanding provides the foundation for forming close relationships (Hartup &
Stevens, 1999), as the quantity of friends is replaced by the quality of relationships
and “best friends” are valued for their intimacy and loyalty (Buhrmester, 1996).
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Clinical and Educational Child Psychology
Cliques and crowds Part of adolescent identity formation involves aligning oneself
with a smaller group of similar peers (cliques) or larger groups of similar aged peers
(crowds). These groups often form a reference group for the adolescent, providing
a set of shared standards that may be based on activities (such as sports or music) or
characteristics (e.g. popular) of the members. According to Newman and Newman
(2001), cliques and crowds are important facets of an adolescent’s developing understanding of his or her social world; while cliques provide the opportunity for social
networking and experimenting with different roles and values, crowds provide a sense
of security in a larger context, separate from family.
Social status
Popular or controversial adolescents have more close friends, engage in more
extracurricular school programs, and are less lonely than less popular peers. By
contrast, rejected and neglected adolescents are more likely to feel lonely, engage
in fewer activities, and have fewer friends (Franzoi, Davis, & Vasquez-Suson,
1994).
Gender and friendships Girls desire more emotional closeness in friendships than
boys (Markovits, Benenson, & Dolensky, 2001), while boys seek activity-oriented
companions to engage in sports or games (Buhrmester, 1996). However, close emotional ties can have positive and negative outcomes, since girls are twice as likely to
report disagreements with friends over interpersonal issues (Hartup & Laursen, 1993).
Attachment and adolescent outcomes
Secure attachment Attachment has been previously discussed at a theoretical level
(Chapter 2) and in its relationship to outcomes in early and middle childhood (Chapter 3). Attachment theory (Bowlby, 1982) can provide a framework for understanding
the development of social-emotional relationships across the lifespan. As previously
discussed, adolescence is a time of increased focus and attention on establishing relationships with others, “transferring” attachment styles from parents to peers, partners,
and social groups (Allen, 2008). It is a time when adolescents shift their attachment
system with parents from proximity to availability, as parents take on the role of a safe
haven or secure base from which to venture out into the social arena (Markiewicz,
Lawford, Doyle, & Haggart, 2006). Securely attached adolescents experience more
satisfying personal relationships that are based on a system of trust and concern for
others’ welfare (Larose & Bernier, 2001; Mikulincer et al., 2003) and demonstrate a
more coherent sense of identity and positive well-being (Mikulincer, 1995). Longitudinal studies tracking individuals from early childhood until their late twenties have
found that secure attachment is related to increased self-reliance, better emotional
coping, and enhanced social competence (Sroufe, 2005). Other positive outcomes for
adolescents with secure attachments include: fewer internalizing problems (DeKlyen
& Greenberg, 2008); less drug use (Schindler, Thomasius, Gemeinhardt, Kustner,
& Eckert, 2005); less likelihood of engaging in risky sexual behavior; fewer suicide
attempts; and less antisocial behaviors (Allen, Moore, Kuperminc, & Bell, 1998;
Developmental Milestones: Adolescence
97
Williams & Kelly, 2005). Securely attached adolescents are more successful in school,
both socially and academically (Rubin et al., 2004; Simons, Paternite, & Shore, 2001).
Insecure attachment In their study of attachment styles in adolescents in the United
States, Lee and Hankin (2009) suggest that insecure attachment may be a risk factor
for the development of later depressive and anxiety disorders. Other studies have
supported this suggestion, demonstrating that adolescents with anxious–avoidant
attachment patterns may become isolated, as they distance themselves from peers
at a time when the majority of youth are increasing and strengthening their social
relationships (Dozier, Lomax, Tyrrell, & Lee, 2000). Compared to their secure or
anxious–avoidant peers, adolescents with an anxious–resistant attachment pattern
demonstrate poor ability to regulate emotions and cope with distress, resulting in a
higher frequency of anxiety disorders, depressive symptoms, and potential for later
diagnosis of borderline personality disorder (Cassidy, 1994). Adolescents with this
pattern may also experience rejection from peers because they appear too “needy” or
due to excessive or inappropriate self-disclosure (Mikulincer, 1995).
In their study of a community sample of youth in early adolescence, Allen, Porter,
McFarland, McElhaney, and Marsh (2007) found that insecure attachment was linked
to multiple dysfunctional patterns that remained stable over the three-year investigation. Compared to their securely attached peers, insecurely attached youth exhibited
more depressive symptoms and increasing levels of externalizing behaviors over the
three-year period.
The worst outcomes for psychopathology are evident across the lifespan for youth
with a disoriented–disorganized attachment pattern, which is often associated with
a family history of abuse and inconsistent parenting which does not allow for the development of a consistent internal working model for future relationships. Adolescents
with this pattern may demonstrate externalizing disorders (disruptive behaviors such
as oppositional defiant disorder or conduct disorder), internalizing disorders (anxiety
and depression), or a combination of both (Moss, Cyr, & Dubois-Comtois, 2004).
Attachment and the parent–adolescent relationship In their study of early adolescent Italian youth, Sarracino, Presaghi, Degni, and Innamorati (2011) found that
adolescents were more securely attached to the parent of the same sex, although
attachment security to the parent of the opposite sex was predictive of a more moderate social value system, evident in more traditional and conservative beliefs, and fewer
problem behaviors.
The role of parents in adolescents’ secure attachment has also been investigated in
terms of adolescents’ relationships with their mothers (Allen et al., 2003) and their
fathers (Allen et al., 2007) and conflict resolution. These studies have demonstrated
that adolescents who have a secure relationship with their parents are better able to
handle negotiations about autonomy compared to their insecure peers. Furthermore,
youth with insecure attachment patterns report more harsh methods of conflict management used by fathers, compared to peers who are securely attached (Alber & Allen,
1987). Allen et al. (2007) suggest that their results point to the distinct possibility
that “the secure adolescent tends to create relationships characterized by a balance of
autonomy and relatedness to create their own secure bases” socially, and that these
relationships can serve to buffer the adolescent from “peer pressure to engage in
negative behaviours” (p. 1235).
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Parenting styles and adolescent outcomes
Bronfenbrenner’s (1979, 2001) bioecological model places the family in a pivotal
position of influence on child and adolescent development. As a result, the impact
of parenting styles on adolescent emotional and social development has attracted
the attention of significant research. As was just discussed, adolescents who have an
insecure attachment pattern report more harsh parenting tactics than their securely
attached peers.
Baumrind (1991, 2005) has investigated the influence of parenting styles on development, especially with respect to autonomy in adolescence. In her studies with
adolescents, Baumrind (2005, p. 63) found that “intrusiveness and low parental
support” associated with the authoritarian directive approach was related to maladjustment in adolescence. In addition, “demandingness” had a “more beneficial
effect when embedded in an authoritative configuration than when embedded in an
authoritarian configuration” which conjointly provided “firm behavioral control and
monitoring with warmth and autonomy support.” Furthermore, Baumrind (2005,
p. 63) found that high responsiveness affects children positively when conjoined with
high demandingness in an authoritative configuration, but not when conjoined with
low demandingness in a permissive pattern. Ultimately, Baumrind (2005, p. 67) suggests that the success of the authoritative parenting style is associated with enhanced
adolescent autonomy and is based on the “unique configuration of high warmth,
autonomy support and behavioral control and minimal use of psychological control.”
In this case, psychological control refers to what Barber and Harmon (2002) describe
as parent responses of guilt, withdrawal of love, and ignoring, which are perceived
by adolescents as intrusive and manipulative. Although authoritative parents assert
their power in order to support their directives, they balance this with support for the
adolescent’s autonomy in their encouragement of the adolescent’s ability to engage
in critical reflection and reasoning (Baumrind, 1991).
According to domain theory, adolescents will likely take the most issues with
parental attempts to control facets of the personal domain versus the prudential
domain, resulting in parent–child conflict (Baumrind, 2005). Smetana (1995) studied
parenting and its relation to family conflict and found that a less authoritative parent
style was related to more frequent adolescent–parent conflict. In this study, parents
with an authoritative style were more definitive in selecting issues that they should
have control over, and were more likely to be permissive if an issue fell within the
adolescent’s personal domain.
Give a little, gain a lot
Results from research by Smetana (1995) suggest that it is important to choose
your battle ground with adolescents.
Parenting style and other adolescent behaviors Patock-Peckham, King, MorganLopez, Ulloa, and Filson Moses (2011) investigated the role of parenting style in
male and female impulsiveness, and drinking control in emerging adults (university
Developmental Milestones: Adolescence
99
students, 18–21 years of age), and found that lower monitoring by the opposite gender parent was related to impulsivity and alcohol problems. For females, having a
permissive father was linked to lower monitoring and increased alcohol problems and
impulsive behavior, while for males, having a permissive mother was related to lower
monitoring and increased impulsiveness and alcohol problems. Having an authoritative father or mother was linked to fewer alcohol problems and less impulsivity.
In another study, involving 16- and 17-year-olds, Ginsburg, Durbin, Garcia-Espana,
Kalicka, and Winston (2009) found that compared to teens with uninvolved parents,
teens with authoritative parents experienced almost 50% less risk of being in a car
accident, while 71% reported that they were less likely to drive while intoxicated, and
were less likely to use a cellular phone while driving. Youth with authoritative or
authoritarian parents were also twice as likely to wear seat belts and less likely to speed
compared to teens with uninvolved parents.
Family parenting styles and adolescent outcomes When Baumrind (1973) conducted her initial research on parenting styles, she only included families (mothers
and fathers) who demonstrated the same parenting style (authoritarian, authoritative,
indulgent). Fletcher, Steinberg, and Sellers (1999) investigated the impact of different
combinations of parenting styles utilized within the same household. Results revealed
that having one parent with an authoritative parenting style was related to higher
academic competence in adolescents. However, the combination of one authoritative
and one authoritarian parent resulted in increased internalizing distress in adolescents.
Recently, Simons and Conger (2011) evaluated the relationship of parenting styles
(by gender and type for 16 different combinations) to depression, conduct problems,
and academic commitment. Results revealed that certain combinations were fairly
common, such as authoritative mother and indulgent father, or indulgent mother
and uninvolved father, while other combinations were extremely rare (authoritarian mother/authoritative father; indulgent mother/authoritarian father; uninvolved
mother/authoritarian father). Family parenting styles associated with the best outcomes were two authoritative parents, or an authoritative parent combined with an
indulgent parent. The worst outcomes were associated with an uninvolved mother,
combined with an uninvolved or indulgent father, or having two authoritarian parents. Having at least one parent who is authoritative resulted in significant differences
for depression, delinquency, and school commitment, although adolescents who had
two authoritative parents demonstrated the lowest levels of depression and the highest
levels of academic commitment. Although Baumrind (1991) suggested that a typical
family might consist of a nurturing mother and controlling father, Simons and Conger
(2011) found no evidence to support Baumrind’s theory, since virtually no families in
their study represented this combination of styles.
Attachment and parenting style: a summation Adolescence is a time of increased
individual challenges and a time for negotiation to meet a growing need for autonomy.
Youth who are securely attached and have authoritative parents have a more cohesive
sense of self, have a better sense of relationships that include both autonomy and
relatedness, and are better equipped to handle the challenges of this developmental
period and to be successful academically and socially. On the other hand, youth who
are insecurely attached often experience a parenting style that is harsh and critical, and
are at increased risk for developing depressive symptoms and externalizing behaviors.
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5
Development from a Clinical
and Educational Perspective
Chapter preview and learning objectives
Developmental deviations: clinical and educational perspectives
Steps in the decision-making process
Assessment and evaluation
Assessment methods
Interviews
Observations
Rating scales
Functional behavioral assessment (FBA)
Clinical and psychometric instruments
Diagnosis and classification
Categorical classification systems
DSM
ICD
DSM and ICD: a comparative view
Strengths and limitations of the categorical systems
Dimensional classification system
Achenbach System of Empirically Based Assessment (ASEBA)
Strengths and limitations of the dimensional classification system
Issues in classification: clinical and educational perspectives
Research methods in child psychopathology
Descriptive research and methods
Naturalistic observation and laboratory observation
Correlational research and methods
Descriptive methods and statistical measurement
The experimental method
Developmental considerations in child research
Qualitative research and mixed methods
Ethical concerns and challenges in practice and research
References
Clinical and Educational Child Psychology, First Edition. Linda Wilmshurst.
© 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.
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Development from a Clinical and Educational Perspective
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Chapter preview and learning objectives
One of the major challenges facing psychologists working with children and adolescents is distinguishing normal behavior from behavior that is atypical or maladaptive.
In Chapter 1, readers were introduced to Pat, a 12-year-old boy who had a history of
academic difficulties and who was responding to academic frustrations with increased
emotional reactivity. Within the context of that case study, readers were briefly introduced to a discussion of clinical and educational approaches to diagnosis and treatment/intervention for Pat. In this chapter, the discussion will focus on the decisionmaking process involved in the assessment, diagnosis, and treatment/intervention
programs for child and adolescent problems. The chapter closes with a discussion of
ethical challenges facing practitioners who work with children and adolescents in their
practice and research settings.
After completing this chapter, readers will have an increased understanding of:
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clinical and educational perspectives concerning the nature and severity of child
problems;
assessment as an on-going process of generating hypotheses about behavior;
various methods used by psychologists to assess child and adolescent behavior;
data gathering, problem solving, and developing interventions;
the different systems used to classify child problems (dimensional and categorical
classification systems);
global issues in the use of different categorical classification systems (the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International
Classification of Diseases (ICD));
the strengths and limitations of the different classification systems;
descriptive and experimental research methods in child psychology;
strengths and limitations of the different research approaches;
ethical concerns and considerations in working with children and adolescents.
Developmental deviations: clinical and educational perspectives
Developmental milestones provide benchmarks for evaluating deviations from the
norm. Although a three-year-old child might frequently engage in tantrum behaviors,
the same behaviors in an eight-year-old would be cause for concern. Not all behavioral
deviations will be that obvious, hence the question: When is a behavioral deviation
from the norm considered serious enough to warrant intervention?
It is likely time to intervene when the behavior is . . .
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developmentally inappropriate;
occurring with greater frequency than anticipated;
occurring with greater severity than expected;
causing concern for the safety of the child or others;
causing significant dysfunction (school, home, peers);
causing significant distress to the child or caregiver.
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Steps in the decision-making process
In order to make decisions about the nature and severity of dysfunctional behavior,
practitioners need to have a plan of action that will inform the decision-making process.
In the case of child and adolescent development, the practitioner will need to assess
the behavior(s) carefully, taking into consideration developmental expectations, and
known risks and protective factors given the child’s age, gender, and culture.
Step 1 – assessment The first step in the decision-making process is assessment.
Assessment is a term that has come to be associated with “testing,” although on a
broader level, assessment can also be seen as a process that involves the on-going
evaluation of behaviors and situations/events, or monitoring of treatment outcomes.
In the latter sense, the goal of assessment could be to develop a diagnosis concerning
the dynamics of the problem; for example, what caused the problem (precipitating
cause) and what is maintaining the problem (maintaining cause). Assessments can
measure development in broad areas of functioning, such as cognitive, behavioral, or
emotional assessments, or they can pinpoint specific areas, such as determining one’s
level of depression (syndrome specific test) or self-esteem.
Step 2 – diagnosis and classification In addition to conceptualizing diagnosis
as a process of inquiry, the term diagnosis can also refer to taxonomy and specific
nomenclature, or how disorders are classified. The goal is to define the problem in
a way that is diagnostically relevant, by classifying symptoms or characteristics within
a specific diagnostic category (learning disability, anxiety disorder, and so on). Once
the “problem” is diagnosed, then the psychologist can access empirically supported
methods that are available to treat the disorder.
Initially, this form of information gathering may produce a number of provisional
diagnoses (hypotheses) that will be confirmed or rejected during the course of the
evaluation.
Ultimately, on the basis of information derived from interviews, observations, and
responses to different types of assessment instruments, the problem becomes more
clearly defined and a specific intervention or treatment can now be recommended.
Step 3 – treatments and interventions Throughout this book, interventions and
treatment alternatives will be discussed as they relate to specific child and adolescent
problems. There has been increasing emphasis on the “end usability” of developmental
research to inform child intervention and treatment:
Within developmental studies, there has been increased focus on the connection between
normative development, atypical development and intervention, including the importance of understanding atypical development through a normative lens that can guide
interventions.
(Guerra, Graham, & Tolan, 2011, p. 7)
To this end, Cicchetti and Toth (2006) have emphasized the need for research to
investigate and improve our “understanding of the mechanisms and processes that
initiate and maintain the developmental pathway to disease” (p. 621).
Development from a Clinical and Educational Perspective
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As will become evident throughout these chapters, treatments and interventions
can be delivered in a number of different settings (clinics, schools, home) and can
be based on a number of different theoretical perspectives (behavioral, cognitive,
psychodynamic, family systems). In addition, treatments and interventions can target
outcomes in a number of different areas, including child outcomes (enhanced child
functioning in academic, social, emotional, and behavioral areas) and family outcomes
(improved quality of life, stress reduction, and reduced level of family chaos).
Assessment and evaluation
Three primary goals of assessment and case formulation include:
1. problem identification, clarification, and classification;
2. problem interpretation and problem evaluation;
3. treatment formulation. (Wilmshurst, 2008, p. 149)
Mash and Hunsley (2005) outline a number of forms that assessments can take,
including: diagnosis (case formulation), screening (at-risk populations), prognosis
(charting the course of a disorder), and the monitoring and evaluation of treatment.
Assessment methods
There are many assessment instruments available to evaluate functioning in broad
areas of learning and achievement, neuropsychological development, emotional and
behavioral concerns, as well as measures to evaluate syndrome-specific concerns (such
as depression, anxiety, and so on). The purpose of this section is not to provide an
exhaustive review of assessment instruments but to provide information about how
these methods assist psychologists to arrive at decisions about diagnosis and treatment
or intervention.
In their survey of school psychologists in the United States, Shapiro and Heick
(2004) found that intelligence testing (84%) was the most common form of assessment, followed by the use of interviews, behavioral rating scales, and observations
(67–75%).
Interviews Interviews provide an opportunity to obtain significant information about
a child’s medical, developmental, and educational history; family history; parental
expectations; and parent and teacher perceptions of the problem. Interviews can take
a variety of forms and can be highly structured, semistructured, or unstructured.
Depending on the nature of the problem, practitioners often want to obtain information from parents and teachers prior to seeing the child or adolescent. When
interviewing a child, it is important to engage the child at a developmentally appropriate level, and establish rapport prior to asking more difficult questions. Unstructured interviews allow for considerable flexibility and are useful for obtaining initial
impressions about the problem, or parent/teacher expectations about potential outcomes. Semistructured interviews provide opportunities for obtaining specific information, but also have built-in flexibility to allow deviation from the structure along
the way. The Semistructured Clinical Interview for Children and Adolescents (SCICA;
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McConaughy & Achenbach, 2001) is an example of a semistructured interview. The
SCICA contains specific questions (which can later be ranked and scored), in addition
to some open-ended questions. Children can also participate in semistructured interviews depending on their age, as part of the interview process. For example, the initial
part of the Achenbach System of Empirically Based Assessment (ASEBA; Achenbach
& Rescorla, 2001) contains a number of specific questions for youth which can later
be scored, as well as a number of open-ended questions (such as “Please describe the
best things about yourself ”). These initial questions become part of the overall evaluation of adaptive functioning on the ASEBA. The mental status exam is a specific type
of semistructured interview designed as a quick check to determine an individual’s
orientation in time and space. For example, an adolescent who appears somewhat
dazed and confused might be asked questions about current events (day and time),
math calculations, and questions requiring insight and judgment (Sattler & Hodge,
2006, p. 638).
The most rigid form of interview is the structured interview which asks very
specific questions with a goal of obtaining information to confirm or rule out a potential diagnosis. This type of interview is also helpful in obtaining information about
demographics or historical background when retaining the sequence of information
is important.
Strengths and limitations of the interview While interviews can provide a wealth
of information, it is not always possible to determine whether an individual is completely truthful about the information (wanting to project a socially desirable image),
whether information is recalled accurately, or the extent to which personal bias alters
recall.
Observations There are several methods of observation that can be used to assist in
the development of a functional behavioral assessment, or to monitor behaviors once
a plan is set in place. The observational methods discussed below are summarized in
Table 5.1.
Narrative recording This procedure involves keeping an anecdotal record of behaviors and events as they occur. Often this can represent the first stage of observation
where the psychologist obtains a general impression of the nature and types of behaviors that are occurring. Although this form of observation provides an opportunity to
see cause and effect connections, information may be subject to observer drift (losing
focus, becoming distracted, or missing key elements).
Event recording Recording of discrete events is helpful in measuring low frequency
behaviors (e.g., the number of times a child raises his or her hand to ask a question) or
the amount of lapsed time between a request and a response. For example, it may be
important to determine the length of time between when a teacher or parent makes a
request and the child initiates a response. Recording can often take the form of a tally
sheet with pre-recorded responses. This is the preferred method for low frequency
behaviors. However, the disadvantage is that information is not obtained about why
the behavior occurred.
Development from a Clinical and Educational Perspective
Table 5.1
111
Methods of recording observed behaviors
Observation type
Appropriate use
Description
Event recording
Discrete, low frequency
behaviors, e.g., the child
asks a question, raises
his/her hand, or talks out
of turn
Continuous behaviors, e.g.,
on-task behavior,
remaining seated, etc.
Record the number of times a behavior
occurs during an observational
period.
Interval recording
Template matching
child
Record alternate
observations of the target
child’s behavior and that
of another “model”
student
Measurement is contingent on
pre-determined time intervals. The
observer creates a time schedule
(e.g., observe behavior for 15
seconds at the top of each minute).
Recording behaviors at one-minute
intervals provides a high yield of
behavioral observations (i.e., it is
possible to record 30 observations in
30 minutes).
This method can be adapted to either
event or interval recording
depending on the nature of the
behavior to be observed.
Information about the frequency of
the model child’s behaviors can be
used to set goals for the target child.
Interval recording Interval observations are best used for continuous behaviors
(e.g., on-task behavior) which are best recorded through timed intervals (e.g., observing every 60 seconds to determine whether on-task performance is evident for the next
20-second interval and recording a “yes or no” on a tally sheet). The process would
be repeated each minute and would allow for 30 (20-second) observations within a
half-hour period. If more than one observer is present, it is also possible to obtain an
estimate of inter-rater agreement for the behavior observed.
Template matching child In addition to the target child, the observer also observes
an exemplary child to determine the optimum ratio of on-task behavior in a 30-minute
period (using the event recording procedure above, with the first 20 seconds viewing
the exemplary child and the second 20-second period observing the target child). This
provides the advantage of having a benchmark to compare the behavior to, rather than
selecting an arbitrary ideal.
Rating scales Behavioral rating scales are an effective and efficient method of obtaining information from multiple informants about a child’s behavior in a number of
important areas. Behavioral rating scales such as the Achenbach System of Empirically
Based Assessment (ASEBA; Achenbach & Rescorla, 2001), the Devereux Behavior
Rating Scale – School Form (DSMD; Naglieri, LeBuffe, & Pfeiffer, 1994), and the
Conners’ Rating Scales (CRS-R; Conners, 1998) provide parallel forms that can be
completed by parents, teachers, and children (of certain ages) regarding behaviors
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Table 5.2
Examples of the types of question that might be found in a behavior rating scale
Please complete the following statements
regarding the child’s behaviors during the last
six months
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Not
true (0)
Somewhat
true (1)
Always
true (2)
Fails to finish assignments, tests
Argues
Prefers to be alone
Enjoys playing sports
Restless
Complains of headaches
Has a friend stay over
Has destroyed an article of personal or family
value
Gets into fights
Complains of stomach aches
in a number of areas (self-concept, social skills, aggression, attention and concentration, learning style). Syndrome scales can also be helpful in having parents, teachers,
and youth rate levels of emotional distress (such as depression, anxiety) relative to
similar-aged peers.
Behavioral rating scales, such as the ASEBA and Devereux scales, are popular for
several reasons, including the following:
r
r
r
r
r
They are in a multi-rater format (parents, teachers, and older children can complete
the questionnaires).
Behaviors are surveyed across a variety of areas.
The responses are hand-scored or computer-scored and generate a behavioral
profile.
The profile allows for a comparison of a child’s behaviors with normative data
available for similar-aged peers.
Rating scales are empirically supported and derived.
The statements contained in Table 5.2 are similar to those found in many of the rating
scales used to evaluate behaviors.
We will revisit the topic of behavioral rating scales later in this chapter, when
discussing the dimensional classification system. An example of a behavioral profile
generated by a behavioral rating scale is available in Figure 5.1.
Functional behavioral assessment (FBA) Derived from applied behavioral analysis
and the behavioral model, a functional behavioral assessment (FBA) is a tool that
allows psychologists to develop a behavioral intervention plan, based on systematic
observation and analysis of the problem behavior as it relates to events/situations
that precipitate the behavior (antecedent condition) and the possible environmental
factors that reinforce and perpetuate the problem (consequence). Unlike the psychoanalytic perspective which attributes behavior to internal and unconscious origins, the
behavioral perspective conceptualizes patterns of behavior as learned responses that are
Development from a Clinical and Educational Perspective
113
Behavioral profile: teacher rating
N
on
-c
om
A
gg
r
pl
es
si
on
ia
nc
e
n
A
tte
nt
io
A
nx
io
M
us
97%ile
93%ile
oo
d
T scores
George
100
95
90
85
80
75
70
65
60
55
50
45
Problem behaviors
Behavioral profile: parent rating
on
e
es
gg
r
A
N
on
-c
A
om
pl
tte
ia
si
nc
io
nt
io
nx
A
M
n
us
97%ile
93%ile
oo
d
T scores
George
100
95
90
85
80
75
70
65
60
55
50
45
Problem behaviors
Normal behavior range
Borderline clinical range
Clinical range
T score 40–60
T score 65–69 (93rd percentile)
T score 70+ (98th percentile)
Figure 5.1 Example of a behavioral profile based on teacher and parent ratings.
based on external conditions of reinforcement and punishment (i.e., we are motivated
to increase behaviors that are rewarded and decrease those that are punished).
FBA is a “multimethod, multisource approach to identify relationships between
specific individual characteristics and contextual variables that trigger and maintain
behaviour” (Hawkins & Axelrod, 2008, p. 841). In the United States, the reauthorization of the Individuals with Disabilities Education Act (IDEA, 2004) and the
focus on early intervention have drawn considerable attention to FBA and its potential
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Clinical and Educational Child Psychology
role in developing intervention plans. As a result, FBA has been the focus of significant empirical investigations in an attempt to “bridge the gap between research and
practice” (Hoff, Ervin, & Friman, 2005, p. 46). Recent investigations have applied
FBA methods to interventions and treatment plans for a host of child and adolescent
behavior problems, in the classroom (Hoff et al., 2005; Moore, Anderson, & Kumar,
2005) and home environments (Hawkins & Axelrod, 2008).
Target the deficit or the excess?
In developing a behavior management program, it is always best to select a
behavioral deficit (such as non-compliance, or off-task behavior) rather than a
behavioral excess (such as aggressive behaviors, or getting out of seat), since
this provides the opportunity for increasing positive outcomes.
An example of a FBA for home-based intervention Hawkins and Axelrod (2008)
examined the effectiveness of FBA methods applied to on-task homework behavior
for four male residents in a group home under the supervision of a trained married
couple who provided a family-style living arrangement using a token economy as a
motivational system. The males were between 12 and 16 years of age and had diagnoses of attention deficit hyperactivity disorder (ADHD) and oppositional defiant
disorder (ODD). Youth attended an on-site school, and were responsible for completing homework at the group home after school. The researchers interviewed the
staff, reviewed records, and conducted a narrative observation of homework periods.
Based on the information, it was hypothesized that all four students were capable of
completing the homework and that off-task behavior during homework was motivated
by wanting to escape task demands, rather than an inability to do the task (Hawkins
& Axelrod, 2008, p. 845). After collecting baseline data, youth were told that if they
worked for 10 minutes, they would receive a reward immediately after the 10-minute
period was completed. Rewards represented one of three conditions: break alone (five
minutes); break with preferred activities (five minutes); or an edible treat. Results
revealed that three of the youth made the most significant improvements in on-task
homework behavior following the five-minute break (alone) conditions.
An example of a FBA for school-based intervention Hoff, Ervin, and Friman
(2005) assessed the effectiveness of applying a FBA intervention for a 12-year-old
boy who was diagnosed with ADHD/ODD and who was disruptive in the regular classroom. Interviews, a review of records, and observations (with partial interval
recording) revealed a number of disruptive verbal behaviors (talking to peers, making
noises) and intrusive behaviors (making faces, taking others’ possessions, getting out
of his seat). The analysis revealed that during the structured portion of the lessons, the
boy’s behaviors were very similar to his peers. However, when the teacher assigned
a task to the class, and then walked around to check their homework and answer
questions, his disruptive behavior increased dramatically. Two potential hypotheses
were generated: disruptive behavior was motivated by trying to attract peer attention;
or it was motivated by escape from a task of little interest to him. Teacher comments
Development from a Clinical and Educational Perspective
Table 5.3
115
Examples of functional behavioral analysis
Antecedent
condition
Behavior
Consequence
What happened
Teacher asks the
child to read
out loud to the
class
Mother requests
clean-up time
Child acts out in
class
Child is removed
from class
Child refuses to
clean up his toys
Mother cleans up
Child calls himself
“stupid”
Child is ignored
by peers
Child feels
depressed
Child tries to get
peers’ attention
Feelings of low
self-esteem
Child is rejected by
peers
Reinforcement:
reading is removed,
avoidance is
reinforced
Reinforcement:
clean-up is removed,
avoidance is
reinforced
Reinforcement: child
feels worse
Punishment: child
withdraws
during the interview referred to his acting “silly” and being the “class clown,” which
gave more credence to the “attention-getting” hypothesis. Further observation confirmed that his behavior was rewarded by peer laughter and attention more than half
the time, but also that his behavior was more disruptive when the task assigned was
silent reading (escape).
Further examples of FBA can be found in Table 5.3.
Recall that in Chapter 2, when discussing different reinforcement and punishment
paradigms, reinforcement always resulted in an increase in behavior (in Table 5.3,
avoidance is reinforced), while punishment resulted in decreased behaviors (social
interaction declines). The psychologist can use this information to develop an intervention plan to reinforce replacement behaviors that are adaptive as opposed to maladaptive. An example of this will be presented in the case of George Nash, to be
discussed shortly.
Clinical and psychometric instruments In addition to rating scales and observation, an
assessment battery (a group of instruments) can be selected to conduct an assessment.
Information concerning the validity (the degree to which the tests measure what
they purport to measure), reliability (the likelihood of obtaining the same score
on test/retest and between raters), and the population upon which the tests were
standardized are available in the instruments’ technical manuals.
Reliability and validity
Reliability is a measure of a test’s consistency across administrations (an individual takes the same test at Time 1 and Time 2 (test-retest reliability)), or the
extent of agreement between two test administrators or observers evaluating the
same individual (inter-rater, or inter-observer reliability). The term validity
refers to the extent that a test measures what it intends to measure, including:
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Clinical and Educational Child Psychology
the degree to which test items represent the entire range of possible items (content validity) and the extent to which the test can predict the construct that is
being measured (criterion validity).
Individual psychometric instruments There are many possible explanations for a
child’s academic and behavioral difficulties, including the fact that behaviors may be a
response to frustrations resulting from problems in information processing, memory,
or cognitive ability. An intelligence test or a measure of cognitive functioning might
provide valuable information about strengths and weaknesses that a child brings to
the learning task, while neuropsychological tests can provide information about
executive processing, memory, and attention. Standardized achievement tests can
provide an index of academic functioning relative to standard intelligence scores to
allow direct comparison of these two levels (an approach called the discrepancy formula
or discrepancy criterion, which will be discussed at length in Chapter 8).
A practitioner who is concerned about a child’s emotional status may conduct
a personality assessment or administer response inventories aimed at more specific emotional difficulties (such as anxiety, depression, somatic concerns, disruptive
behaviors).
Projective assessments Asking children to draw a picture of a person or their family,
or to tell a story in response to pictures, are forms of projective assessment. Information can be analyzed for content of recurring themes such as feelings of powerlessness,
feelings of isolation, family cohesion, and sibling rivalry.
Diagnosis and classification
After assessment and evaluation, the next step is to identify how the problem is classified, relative to other problems. Practitioners are guided in the decision-making
process through the use of systems of classification that clarify the nature of the problem, its causes, course, and treatment alternatives. The classification system provides
professionals with a “common” language for accessing and discussing relevant information about the disorder. There are two main systems of classification for child and
adolescent disorders: the categorical classification system, and the dimensional or
empirical classification system.
Categorical classification systems
The two most widely used categorical systems for the classification of mental diseases
or disorders are the International Classification of Diseases (ICD-10; WHO, 1992),
and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; APA,
2000). Both systems are currently in the process of revision and historically there has
been a concentrated effort to align the two systems, although some differences exist
in how the disorders are conceptualized and in the terminology used.
Development from a Clinical and Educational Perspective
117
Although the two systems share the same goal, the DSM provides more explicit
rules and criteria to guide the decision-making process. The ICD is most frequently
found in Europe, while the DSM is predominantly used in North America. The ICD
is the most frequently used system, worldwide, for clinical diagnoses and training,
while the DSM is the source that is most often used for research (Mezzich, 2002).
Comorbidity and classification
Children tend to experience a significantly higher number of comorbid (cooccurring) disorders compared to adults. A major difference between the ICD
and the DSM, which has important implications regarding the diagnosis of
child psychopathology, is that while the ICD seeks to determine a predominant
diagnosis, the DSM allows for comorbidity for as many diagnoses that meet the
criteria (Kolvin & Trowell, 2002).
Despite the differences in these two diagnostic systems, they share a categorical
decision-making format; namely, a disorder is considered to be present or absent
based on the degree of “fit” between the symptom presentation and the defining
criteria. What follows is a brief description of each of the categorical systems.
DSM The DSM contains classification criteria for over 400 mental disorders. Child
and adolescent disorders occur throughout the manual but are primarily concentrated
in sections devoted to neurodevelopmental disorders (intellectual developmental
disabilities (IDD), autism spectrum disorders (ASD), specific learning disabilities
(SLD), motor skills impairments and specific language impairments (SLI), disruptive behavior disorders (ODD, CD), and disorders of attention, overactivity, and
impulsivity (ADHD)).
Child symptoms versus adult symptoms
While adults with depression may often appear “sad,” this is not always the
case with children. The DSM cautions that depression in children may appear
as “irritability.” Furthermore, while adults with post-traumatic stress disorder
(PTSD) may experience flashbacks, young children are more likely to engage in
repetitive play about the trauma.
ICD The ICD provides an international standard for diagnosis and classification for
general epidemiological purposes. Disorders that specifically relate to mental and
behavioral concerns are contained in Chapter V, including disorders with onset
usually occurring in childhood and adolescence. Currently, categories which relate
most specifically to child and adolescent concerns can be found in the following
sections: Mental Retardation (F70–F79), Disorders of Psychological Development
118
Table 5.4
Clinical and Educational Child Psychology
DSM-IV-TR and ICD-10: a multiaxial comparison
DSM-IV-TR
Axis I
Axis II
Axis III
Axis IV
Axis V
ICD-10
Axis One
Axis Two
Axis Three
Axis Four
Axis Five
Name of disorder; if more than one, principal one is listed first
Mental retardation and personality disorders
Any relevant general medical conditions
Psychosocial and environmental problems: e.g., family situation (divorce,
separation, custody arrangements), school or occupational problems,
financial problems, etc.
Global Assessment of Functioning (GAF). Rating on GAF scale from 0
(incapacitated) to 100 (superior functioning). Often rated at intake and
discharge
Clinical psychiatric syndrome. Main diagnosis
Specific disorders of development (speech, language, academic, motor)
Intellectual level (rated on an eight-point scale from highly intelligent to
profound retardation)
Any relevant general medical conditions
Associated abnormal psychosocial situations; two-point rating scale from most
(2) to least (0) severe. Nine categories are available, each with specific
subcategories: 00: No significant difficulty
1. Abnormal intrafamilial relationships 6. Acute life events
2. Mental disorder, deviance, or
7. Societal stressors
handicap in child’s primary support
3. Inadequate/distorted intrafamilial
8. Chronic interpersonal stress
communication
associated with school/work
4. Abnormal qualities of parenting
9. Stressful events/situations resulting
from child’s own disorder/disability
(F80–F89), and Behavioral and Emotional Disorders with Onset Usually in Childhood and Adolescence (F90–F98).
DSM and ICD: a comparative view Although there are many similarities in the
number and nature of disorders represented by each system, differences in classification
are still evident. As will be discussed in Chapter 8, the DSM differs from the ICD-10
in criteria for attention deficit hyperactivity disorder (ADHD; DSM) and hyperkinetic
disorder of childhood (HKD; ICD-10). There are other differences, some subtle and
others not so subtle, that can cause confusion when individuals communicate from
different sides of these classification systems. As each of the disorders is discussed,
similarities and differences in the two systems will be addressed, as well as proposed
changes for future revisions of both systems.
Multi-axial systems Clinicians using the DSM report the client’s problems on each
of five axes, while the ICD uses a six-axis system for reporting child and adolescent
problems (WHO, 1996). A comparison of the two multiaxial systems is available in
Table 5.4.
The six-axis system of the ICD-10, especially Axis Five, provides significant information and draws attention to the many aspects of the child’s psycho-social world
that may impact on functioning, above and beyond the specific disorder with which
Development from a Clinical and Educational Perspective
Table 5.5
119
Empirical and categorical systems: strengths and limitations.
Classification
system
Categorical
classification
system (DSM,
ICD)
Empirical/
dimensional
classification
system
(ASEBA,
BASC2,
Conners)
How disorders are
classified/
conceptualized
Observation, clinical
judgment
Structured and
semistructured interviews
(e.g., NIMH DISC-IV,
K-Sads)
Matching symptoms to
criteria (medical model)
Disorder present or absent
Qualitative and mutually
exclusive
Behavioral rating scales
Empirically derived (factor
analysis)
Symptoms present by degree
Multirater, parallel forms
Syndromes are on continuum
Age-based norms
Degree of variance from the
norm
Internalizing and
externalizing
Quantitative and continuous
Strengths
Limitations
Widely adopted in clinical
practice and research
Acceptance by third-party
payers DSM: multiaxial
presentation and
documentation of
associated features,
nature, and course
Clinical judgment may
vary
Disorders as present/
absent (yes/no)
Mutually exclusive; may
pose problems for
comorbid disorders
Issues of reliability and
validity
Provides a range of
deviation from norm
Developmental norms
Multiple informants
Syndromes can be
comorbid
Can chart progress of
interventions
Quantitative
Not as widely accepted
by third-party payers
Multiple informants may
result in discrepant
information
Issues of reliability and
validity
the child may be diagnosed. For each of the nine situations referred to on Axis Five,
there are several subcategories. For example, “1. Abnormal intrafamilial relationships”
lists five possibilities: 1.0 lack of warmth in parent–child relationships; 1.1 intrafamilial
discord among adults; 1.2 hostility toward or scapegoating of the child; 1.3 physical
child abuse; 1.4 sexual abuse (within the family).
Strengths and limitations of the categorical systems
Strengths The widespread use of the categorical system by clinical professionals
assures its continued use, and dissemination of information about disorders using
prescribed criteria. The all-or-nothing paradigm brings greater clarity to the diagnosis
and the clinical decision-making process. The manuals are often comprehensive and
based on significant field research.
Weaknesses The DSM has been criticized concerning the appropriateness of the
symptoms for child populations, since many of the field trials did not include child
samples. Also, the categorical (all-or-nothing) nature of the symptoms does not support the continuum of symptoms that occurs in childhood. Neither of the categorical
systems can accommodate a continuum, at present, which would be appropriate for
developmental concerns. The strengths and weaknesses of the dimensional and categorical systems are presented in Table 5.5.
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Clinical and Educational Child Psychology
Normal,
Bell-shaped Curve
.13%
4σ
2.14%
–3σ
13.59%
–2σ
34.13%
–1σ
34.13% 13.59%
0
+1σ
2.14%
+2σ
.13%
+3σ
+4σ
Standard deviations
55
70
85
100
115
130
145
70
80
Standard scores
20
30
40
50
60
T scores
Figure 5.2 Standard normal distribution and T scores.
Dimensional classification system
The dimensional classification system conceptualizes problem behaviors along a
continuum of severity. The Achenbach System of Empirically Based Assessment
(ASEBA; Achenbach & Rescorla, 2001) is an example of a dimensional classification
system. Since this system is used on a worldwide basis, it will provide the template for
the following discussion.
Achenbach System of Empirically Based Assessment (ASEBA) The ASEBA has been
translated into 80 languages and has been reported in over 5000 research studies
(Achenbach, 2008; Berube & Achenbach, 2004). Although the entire scale contains 112 (youth self-report form) to 113 (parent and teacher reports) items, factor
analysis has revealed that items cluster into eight syndromes: anxious/depressed, withdrawn/depressed, somatic complaints, social problems, thought problems, attention problems, rule-breaking behaviors, and aggressive behaviors. The ASEBA syndrome scales
were derived based on samples of children from Australia, England, and 40 states in
the United States of America.
Behavioral rating scales and the T score distribution
In a T score distribution, the average T score is 50 and the standard deviation
is 10. Children and youth who score within one standard deviation of the mean
(range of scores between 40 and 60) are considered to score within average
limits. As the scores increase, the cause for concern also increases. The normal
distribution and T score distribution are available in Figure 5.2.
Development from a Clinical and Educational Perspective
121
The ASEBA reports behaviors in terms of T scores that provide an index of the
severity of the behavior relative to normative functioning based on the child’s age
and gender. Scores between 65 and 69 are considered to fall within the Borderline
Clinical Range and in need of monitoring and potential intervention. Scores of 70
or above represent behaviors that are two standard deviations above the mean, at the
ninety-eighth percentile, and are considered to be Clinically Significant. Children
and youth who score in the top 2% of the population are considered to have significant
problems in need of intervention. (See Figure 5.1 for an example of a behavioral profile
and T score distribution.)
Internalizing problems and externalizing problems In addition to the syndrome
scales, there are two broad groupings of syndromes: internalizing problems (behavioral deficits representing a lack of some quality) and externalizing problems (representing behavioral excesses). Symptoms of withdrawal, anxiety, and somatic complaints all fall within the realm of internalizing problems, while rule-breaking behaviors
and aggressive behaviors are considered to be externalizing behaviors. There are high
rates of comorbidity (co-occurring disorders) among the internalizing disorders (anxiety, depression, somatic complaints), and the externalizing disorders (rule-breaking
and aggressive behaviors). It is not uncommon to find a child who is anxious and
depressed, or a child who is aggressive and engages in rule-breaking behaviors. Internalizing and externalizing behaviors may also co-exist (a child may be anxious and
aggressive).
Strengths and limitations of the dimensional classification system
Strengths
r
r
r
r
r
r
r
The strengths of the system lie in its ability to provide:
a continuum of severity from mild to severe;
empirically supported benchmarks;
data that are both quantitative and continuous;
two broad-band behavioral dimensions (internalizing and externalizing);
a multi-rater format;
test and retest data for an index of clinical change before and after intervention;
data that allow for a comparison with ratings for peers of the same age and gender.
Weaknesses Despite a number of strengths, one of the major weaknesses is that the
dimensional system has not been endorsed by some third-party payers (such as insurance companies), and poses difficulties, at times, when multiple informants present
very different profiles concerning the same child. However, different perspectives can
also demonstrate consistency or inconsistency of symptoms across a variety of different
situations (e.g., at home and at school).
Issues in classification: clinical and educational perspectives
While the DSM and ICD provide diagnostic guidelines, there are several limitations
to the usefulness of these diagnoses when working with children, due to the ambiguity and reliance on clinical judgment inherent in these systems. This is especially
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Clinical and Educational Child Psychology
true for children who have “hidden disabilities” which often have common symptom
presentations, and are difficult to diagnose, such as: attention deficit hyperactivity
disorder (ADHD), dyslexia, dyspraxia/developmental coordination disorder (DCD),
autism spectrum disorder, or speech and language difficulties (McKay & Neal, 2009).
Hidden disabilities can be misdiagnosed or can evade a diagnosis altogether.
Global initiatives have targeted early intervention, often by tiered systems of screenings and graduated interventions, such as Response to Intervention (RTI) in the
United States and the All-Wales Strategy for Child and Adolescent Mental Health
(NAW, 2001) in the United Kingdom. However, these systems are not without their
problems and have been criticized for delaying formal assessment and the fact that
more elusive disabilities are less likely to be detected early, and more likely to be misclassified as “delays” rather than disabilities. In their critique of the system in Wales,
McKay and Neal (2009) suggest that “tier 1 frontline services including teaching staff,
school nurses, health visitors, foster carers and other non-specialist key staff ” may not
have the necessary training to detect these hard-to-diagnose conditions (p. 167). As a
result, because the student has not been correctly identified, appropriate intervention
is not provided and instead the child begins the long journey to more punitive types
of interventions (disciplinary activities, detentions) and eventual involvement in the
criminal justice system. Rather than effective engagement, the student becomes progressively disengaged from the system, in a “continuum of disengagement” (McKay
& Neal, 2009, p. 170).
Another area where diagnosis is flawed with respect to the recognition of special needs is in the category of social, emotional, and behavioral disorders (SEBD),
also referred to as emotional and behavioral disorders (EBD). The Special Education Needs: Code of Practice (DfES, 2001) reports there is “a lack of clarity about
which particular groups of children and which behaviours constitute EBD” and where
“behavior problems” and the strategies to contain them differ from more general
discipline problems. At the other extreme, there is lack of clarity as to whether behavior difficulties in school indicate some underlying mental health problems that need
medical or psychiatric intervention. In general, there is a distinction made between
emotional and behavioral difficulties and more deep-seated mental health problems
which require psychiatric interventions; however, the British government has acknowledged that there is some overlap between the group of children with EBD and those
who have mental health problems (DfES, 2001).
Based on their survey of mental health concerns in children and adolescents in
the United Kingdom, using ICD and DSM criteria, Meltzer, Gatward, Goodman,
and Ford (2003) found that 10% of children between five and 15 years of age had
a mental disorder, with 5% meeting criteria for conduct disorder. Within the United
States, 21% of children aged nine to 17 were estimated to have a diagnosable mental
or addictive disorder, with at least minimal impairment, while 11% were considered
to meet criteria for significant functional impairment. Of this sample, approximately
10% met criteria for disruptive disorders (Shaffer et al., 1996).
While the Code of Practice (DfES, 2001) provides a list of general areas that may
be associated with lower academic performance and special education needs (SEN),
such as communication and interaction, cognition and learning, behavior, emotional
and social development, and sensory and/or physical problems, however, it does
not specify criteria, stating instead that it does not assume that there are hard and
fast categories of special educational need. In this way, the Code of Practice differs
Development from a Clinical and Educational Perspective
Table 5.6
123
Summary of quantitative research methods.
Research method/type of
data collection
Data analysis
Descriptive research
Survey
Questionnaires
Case studies
Observation (naturalistic)
Correlational research
Compare pre-existing data
Descriptive data collection
Epidemiological
information
Experimental research
Scientific method, control
group and experimental
group
Strengths and weaknesses
Frequency distribution
Strengths
Measures of central tendency Allows for easy access to data
(mean, median, mode,
Ecological validity (naturalistic settings)
standard deviation)
Case study provides in-depth analysis
Weaknesses
Limited statistical power, rigor, and
control
Limited ability to generalize
Correlation coefficient
Strengths
(Pearson’s r)
Can access large data sources of
Measures of strength (-1 to
pre-existing data
+ 1) and direction
High external validity (generalizability)
(positive or negative) of
Weaknesses
association between
Limited statistical power; cannot imply
variables
causation
Prevalence, incidence, and Low internal validity (low rigor and
lifetime prevalence rates
control)
Statistical methods designed Strengths
to test hypotheses with
High statistical power; can determine
goal to reject the null
causes
hypothesis
High internal validity (rigor and control)
Manipulate variables under Weaknesses
controlled conditions
Limited external validity (narrow band
results may not generalize)
Low ecological validity (controlled or
analogue studies)
significantly from the Individuals with Disabilities Education Act (IDEA, 2004) in the
United States, which outlines 13 categories of disability that are eligible for special
education services and the requirements needed to meet those criteria.
Research methods in child psychopathology
Guided by the scientific method, research goals are to describe, predict, control (prevent), and understand the nature of clinical problems. As a result, research questions
are designed to explore (descriptive methods); to test hypotheses about the relationships among a set of variables (correlational research); or to determine a cause and
effect relationship between two or more variables (experimental research). While correlational research evaluates the association among existing variables, experimental
research involves the actual manipulation of variables under controlled conditions. A
summary of the different types of research methods, their strengths, and their weaknesses can be found in Table 5.6.
More recently, there has been an increased emphasis on “translational” research
in child development in an attempt to develop innovative research programs and
designs that can inform policy and practices, using a blend of basic and applied
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Clinical and Educational Child Psychology
research (Guerra, Graham, & Tolan, 2011). For example, using a qualitative and
mixed methods research approach, Guerra, Williams, and Sadek (2011) interviewed
students about the nature and the causes of bullying and determined that bullying takes
on more sexualized connotations in middle school and high school. Other research
programs have found that certain variables, such as poor literacy, can act as mediating
variable between early poverty and later depression (Kellam, Rebok, Mayer, Ialongo,
& Kalonder, 1994), while other variables can act as moderating variables, such as a
calm and soothing parent who can over-ride the fearful and heightened physiological
reactions of a child with a wary temperament (Kagan & Fox, 2006).
Descriptive research and methods
Descriptive methods increase our knowledge about the relative frequency and distribution of variables in the environment (e.g., do children spend more time studying
or watching television?). Data can be obtained from a variety of methods, including: naturalistic observation, laboratory observation, case studies, or surveys and
questionnaires (paper and pencil, or individual interviews conducted face to face or
by telephone or e-mail).
Naturalistic observation and laboratory observation A researcher may observe a child
playing in a laboratory setting under controlled conditions, or in a natural setting like
the playground.
Strengths and limitations of naturalistic versus laboratory observation Collecting data in a laboratory setting has the advantage of increased control, while the
strength of naturalistic observation exists in the ecological validity of observations
obtained in naturally occurring settings. However, observation is not without its challenges and limitations due to a number of potential biases, including: observer bias,
observer drift (difficulties sustaining attention), central tendency bias (tendencies
to pick the middle category more frequently when rating behaviors), and observer
effect (the fact that individuals tend to alter their behavior when observed). Because
of the lack of control over competing factors and variables, the success of recording behaviors in the natural setting depends to a great extent on which behaviors
are selected and how objectively they are defined. Recall that different observational
methods were discussed earlier in this chapter.
Correlational research and methods Researchers who conduct correlational studies
are interested in how characteristics “co-vary” (e.g., hours of studying and academic
grades).
What is a correlation?
The co-relationship between two variables is defined by a continuum that ranges
from −1 to +1, with +1 indicating a perfect positive correlation and −1
indicating a perfect negative correlation. Characteristics at zero are unrelated.
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Development from a Clinical and Educational Perspective
Hours of studying
Hours of partying
(b). Strong negative correlation
Eye color
(a). Strong positive correlation
Intelligence
(c). No correlation
Figure 5.3 Graphic examples of positive, negative, and zero correlation.
A researcher finds that as hours of studying increase, grades increase, and as television viewing increases, grades decrease. Results indicate a strong positive correlation
( + 0.70) between studying and academic performance, and a modest negative correlation (–0.30) between television viewing and grades. In all cases of correlation, the
number indicates the strength of the association, while the positive or negative
sign indicates the direction of the association. Examples of positive and negative
correlations are presented in Figure 5.3.
Based on this hypothetical study, can the researcher claim that either (a) increased
studying increases grades, or (b) television viewing decreases grades? The correct
answer is that neither of the statements is true. The important point to remember
is that correlation does not imply causation, because we have not controlled for a
possible third factor that may be operating to influence the strength and direction of
the association.
Association versus causation
In the hypothetical correlational study discussed here, there may be several
“other” factors that have influenced grade reduction or increases for these students, including:
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a. students can spend a number of hours studying the wrong material or using
ineffective study methods which would not increase their academic scores;
b. some television viewing might enhance understanding of some academic
material (e.g., documentaries).
Strengths and limitations of the correlational method Correlational research
affords high external validity (it is possible to generalize across a wide variety of
variables, and replicate results to include greater sample variance) and data can be
readily available from pre-existing data bases. However, although one is able to cast a
wide net, the method does not allow for cause and effect inferences, thereby resulting
in low internal validity.
Epidemiological studies Correlational studies that provide information about the
rates of occurrence of different disorders are called epidemiological studies. These
studies inform clinicians about disorder incidence rates (number of new cases of a
disorder within a given period of time; for example, new cases in a given year), prevalence
rates (total number of cases of a disorder within a given time frame), and lifetime
prevalence rates (number of cases of a disorder which might be expected to occur over the
course of one’s lifespan).
Case study The case study is an intense and on-going observation of a single
subject over the course of time. While it has the advantage of providing rich detailed
information, its weakness is the limited ability to generalize the information.
Survey method Surveys can be completed in person, on the telephone, or via the
internet. An obvious strength of the survey method is the fact that it can be an
efficient and effective method of collecting information, in a relatively short period
of time. Weaknesses of the method can include response biases (only those willing to
participate are surveyed; the responses may reflect what is socially acceptable, rather
than reality).
Descriptive methods and statistical measurement The descriptive methods discussed
above can provide information regarding the frequency distribution of the responses
measured, in terms of: percentages, cumulative percentages and percentiles, as well
as the mean (average), median (mid-point), and mode (most frequent response) for
the distribution.
Mean, median, and mode
A student takes a series of exams and produces the following scores out of a
possible 50 points: 35, 48, 20, 50, 35, 42, 40.
In this distribution, the mean (average) score would be 38.5, the median
(mid-point) would be 40, and the mode (most frequent score) would be 35.
Development from a Clinical and Educational Perspective
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The experimental method
The experimental method is the most rigorous method and allows the researcher
to manipulate variables to determine cause and effect relationships. For example, a
researcher hypothesizes that viewing television violence increases aggressive behavior
in children. To test this hypothesis, the researcher must disprove (or reject) the null
hypothesis which states there is “no difference” in the level of aggressive behavior
in children who watch violent versus non-violent television programs. The researcher
randomly assigns children (say, boys aged four to five years) to one of two groups:
a control group (not exposed to television violence) and an experimental group
(exposed to a violent television program). The variable that is manipulated (television
program, violent versus non-violent) is the independent variable and the outcome
(aggressive behavior) is the dependent variable.
A possible research design might be to randomly assign 50 boys, matched for ages
(four to five years) and socio-economic status (SES) to one of two groups:
Experimental Group: watch violent television show (Kung Fu Bears);
Control Group: watch non-violent television show (Cuddle Bears).
For 15 minutes prior to watching the shows, the children are observed playing in a
laboratory play room (baseline record of play before exposure to television program),
and again for 15 minutes after viewing the shows. Toys have been pre-selected for
their violent (guns, punching bag) and non-violent content (blocks, stuffed animals,
building materials). Researchers who are recording play behaviors are blinded (have
no knowledge) as to whether the child is from the control group or experimental
group.
Internal validity The experimental method provides high internal validity, since
controls limit external variability (e.g., the sample has been matched for gender,
age, and SES to limit the extraneous confounds). Play data were collected pre- and
post-viewing and long-term effects were monitored by having subjects return to the
play laboratory two weeks after the experiment and observing them play again. The
researcher has attempted to limit observer/experimenter bias effects by insuring
that the rater was blind to/unaware of group affiliation. If more than one observer
was used, the researcher would have included training periods to establish high rates of
inter-rater reliability (e.g., raters agree on the amount of violent versus non-violent
play within 80% accuracy).
External validity The rigorous and controlled nature of the experimental method
limits the generalizability of the findings. Therefore, while the experimental method
yields high internal validity (experimental control), the “artificial” or “contrived”
nature of the “experimental situation” may result in a lack of ecological validity
(validity of context). In fact, in the example, if the results demonstrate a significant
increase in aggressive behaviors, researchers are bound to limit the nature of these
findings to low SES boys, between the ages of four and five, who watched the program
Kung Fu Bears. To increase generalizability, studies are often replicated to see if results
are similar for different populations (older boys, females, and so on).
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Ethical standards In the above experiment, the researcher has the boys who were
exposed to Kung Fu Bears return for a 15-minute play session two weeks later to
measure any long-term effects. If the children who originally viewed Kung Fu Bears
(the experimental group) continued to demonstrate elevated levels of aggressive play
relative to controls, it could be argued that the study violates the ethical principle
of beneficence and non-maleficence, or the clinician’s duty to “do no harm,” since
exposure to the study created long-term violent behaviors in the subjects.
Quasi-experimental design In some situations, random placement is not possible
and might even be construed as unethical. For example, arbitrarily withholding treatment from one group might be considered unethical. In a wait-list control situation,
the group not receiving treatment can still be used to measure the effects between the
two groups after group one finishes treatment, and then receive treatment in the next
phase. Researchers can also use a matched control group (i.e., compare children that
have been matched for all relevant variables other than the experimental variable).
Empirically based treatments In order to study the effects of specific treatments
for specific problems, studies use replication to determine whether treatment effects
can generalize to different age groups, populations, or the wait-list control. Recall that
in the wait-list control condition, children are not deprived of treatment; treatment is
merely delayed until the experimental group completes their treatment phase.
Single subject experiment In this design, the subject acts as their own control.
In this case, the variable to be manipulated (the independent variable) would be a
clinical intervention and the subject would be observed prior to intervention (baseline
data) and again after the intervention was introduced. This is also referred to as an
ABA design. Many clinicians prefer to add another level of analysis to rule out any
potential confound. For example, George’s on-task behavior has increased after the
introduction of a token economy in his classroom (George can gain 10 minutes of free
play, if he works for three 10-minute sessions on his seatwork). However, the school
psychologist wants to insure that the intervention is responsible for the change in
behavior by ruling out any other source of influence (e.g., George’s desire to impress
a new little red-headed girl who is sitting beside him).
The ABAB or reversal design
The psychologist uses an ABAB design and observes if there is a difference
between behaviors at Time 2, Time 3, and Time 4. If the behavior deteriorates
at Time 3, and improves again at Time 4, then there is strong support for the
claim that behavior improved because of the intervention.
No intervention
Token economy
Remove intervention
Token economy
Condition A
Time 1
Condition B
Time 2
Condition A
Time 3
Condition B
Time 4
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Developmental considerations in child research
The study of behavior over time Studies of developmental pathways or trajectories examine protective factors that serve to buffer the child from harm, or risk
factors that place the child at increased risk. Researchers also investigate how symptoms present at various developmental stages (e.g., depression in a two-year-old may
appear as “acting out,” whereas depression in adolescence may be evident in social
withdrawal). Some children may be more vulnerable to negative influences due to
other risk factors (low self-esteem, poor social skills, learning problems) while others
may be more resilient due to protective factors (family support system, mentors, peer
support, and so on).
Developmental pathways: equifinality and multifinality
Equifinality emphasizes that different pathways can lead to the same outcome.
For example, two children may share symptoms of depression; however, one is
reacting to peer rejection, while the other is in the midst of a custody battle.
Multifinality relates to the fact that very similar paths can produce very
different outcomes. For example, one child whose parents are divorcing may
spend increasing time engaged in athletic competitions, while another child in
similar circumstances may engage in delinquent activity.
Longitudinal, cross-sectional, and accelerated longitudinal designs The longitudinal study (such as a study that follows the course of development of the same
group of children from the age of five to 20 years) has the advantage of measuring
differences in the same population. However, weaknesses of the method include: time,
cost, and loss of subjects over time (subject attrition). A cross-sectional approach
studies change over time in different populations; for example: comparing three groups
of children at three different ages: Group A, five years of age; Group B, 12 years of age;
and Group C, 20 years of age. The design allows for data collection in a relatively short
period of time; however, there is a loss of information about developmental pathways
that might have been evident longitudinally. Another limitation is the possibility of
cohort effects (the three groups of children actually represent different generations
and have been exposed to different environmental factors). One alternative method
that allows for a reduction in time, while protecting against cohort effects, is the
accelerated longitudinal design. Using this method, the researcher might study one
group of children aged five to 12 and a second group of children aged 13 to 20,
thereby effectively reducing his research time commitment by half.
Qualitative research and mixed methods
Historically, the primary research method has focused on quantitative methods (statistical analysis of data); however, there has been an increase in the collection of more
subjective data (such as information from interviews). As a result, more recently there
has been a focus on combining the best of both worlds, in what is referred to as
“mixed methods.”
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Advantages and disadvantages Quantitative methods use statistical analyses of variables to test hypotheses, while qualitative methods focus on information about the
underlying processes or experiences, often obtained through such activities as: focus
groups, observations, or transcripts of interviews. While the goal in quantitative analysis is to find a significant mathematical difference between variables, in qualitative
analysis the focus is on finding the underlying patterns and themes. Strengths of the
quantitative approach include the ability to test hypotheses mathematically, while the
strength of qualitative research lies in the rich information on individual differences
that would be lost mathematically. While the quantitative approach loses information
about “individual differences,” the qualitative approach lacks the ability to prove or
disprove a hypothesis, and may have limited generalizability.
Ethical concerns and challenges in practice and research
Clinicians working with children face many unique challenges. Very young children
may not have adequate insight into their problems or lack the necessary language
to articulate their feelings or concerns. Licensed practitioners are guided by ethical
principles and standards that are monitored by their professional organizations. Some
of the challenges facing psychologists in practice or conducting research with children
and adolescents may include:
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the need to obtain the child’s assent (consent) for participation;
issues of confidentiality when working with adolescents;
the need to determine who is the custodial parent in divided families;
ensuring that the child understands that participation is “voluntary.”
Although different cultures vary in whether practices favor a more individualistic or
collectivistic orientation, there is a universal code, the Universal Declaration of Ethical
Principles for Psychologists (2008), that has been developed to guide psychological
services, globally, which is supported by the International Union of Psychologists, the
International Association of Applied Psychology, and the International Association for
Cross-Cultural Psychology. The Universal Declaration recognizes four aspirational
principles, which are found in most ethical codes, namely: respect for the dignity
of others; provision of competent care; integrity; and professional responsibility to
society.
Do young children understand the concept of
voluntariness?
When Abramovitch, Freedman, Henry, and Van Brunschot (1995) asked 121
children (five to 10 years of age) if they would like to stop participating in the
study, only seven children withdrew. However, when the examiner added “and
I won’t be angry with you if you do stop,” twice as many children terminated
their involvement. The researchers concluded that children may not have an
understanding of the right to “voluntariness” (e.g., that they can withdraw
from participation).
Development from a Clinical and Educational Perspective
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However, there are a number of issues that are unique to working with children
and adolescents that may fluctuate widely based on local laws, including the rights
bestowed to the adolescent once they reach the age of majority, and what that age
represents in that location. This is crucial to granting permission for involvement in
research or therapy, and issues of confidentiality regarding information which may take
place in therapy sessions, or the access to/and dissemination of reports concerning the
adolescent. In the United States and Canada, the age of majority ranges from 18 to
21 years, depending on the state or province in which one resides.
Furthermore, the American Psychological Association (2010, Standard 3.10b) states
that it is a violation of ethics if a psychologist obtains “passive permission” from a
guardian (e.g., asking a parent to return a form only if they desire that their child not
be included in a research study, or therapy program).
References
Abramovitch, R., Freedman, J., Henry, K., & Van Brunschot, M. (1995). Children’s capacity to
agree to psychological research: Knowledge of risks and benefits and voluntariness. Ethics
and Behavior, 5, 25–48.
Achenbach, T. M. (2008). Assessment, diagnosis, nosology and taxonomy of child and adolescent psychopathology. In M. Hersen & A. Gross (Eds.), Handbook of clinical psychology,
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Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the ASEBA school-age forms and
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American Psychological Association (APA). (2010). Ethical principles of psychologists and code
of conduct. Retrieved from http://www.apa.org/ethics/code/index.aspx
Berube, R. L., & Achenbach, T. M. (2004). Bibliography of published studies using ASEBA
instruments: 2004 edition. Burlington, VT: University of Vermont, Department of Psychiatry.
Cicchetti, D., & Toth, S. L. (2006). Building bridges and crossing them: Translational research
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Guerra, N. G., Graham, S., & Tolan, P. H. (2011). Raising healthy children: Translating child
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Part Two
Child and Adolescent Problems
and Disorders
Clinical and Educational Child Psychology, First Edition. Linda Wilmshurst.
© 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.
6
Adjustment Problems and
Disorders in Childhood
and Adolescence
Chapter preview and learning objectives
Introduction to adjustment problems
Symptoms and prevalence of adjustment disorders
Temperament, emotional reactivity, and response to stressors
Five- and three-factor models of personality
Effortful control (constraint)
Behavioral inhibition in high and low reactive temperaments
Adjustment problems in early and middle childhood
Adjustment to school stressors
Transition to school
Role of temperament
Other school-related factors
Adjustment to family stressors
Parental stress and family conflict
Chaos in the home
Divorce and separation
Siblings: allies or rivals
Adjustment to environmental stressors
Neighborhood disadvantage
Peer relationships
Adjustment problems in adolescence
Adjustment to school stressors
School transitions
Role of affect regulation and comorbidity
Adjustment to family stressors
Parenting practices and family cohesion
Siblings
Adjustment to environmental stressors
Peer relationships
Other environmental stressors
References
Clinical and Educational Child Psychology, First Edition. Linda Wilmshurst.
© 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.
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Chapter preview and learning objectives
The first five chapters have provided foundation skills for understanding typical and
atypical behaviors that may be evident at different stages of development. At this point,
the reader has accumulated the necessary tools to address:
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how and why problems may develop in some children from a variety of perspectives
(Chapter 2);
developmental differences and difficulties based on normal expectations, given the
child’s chronological and mental age (Chapters 3 and 4); clinical and educational
perspectives on the nature of diagnosis; different systems of classification; and how
to evaluate problems using several empirical procedures and methods (Chapter 5).
In the previous chapters, we discussed six important questions that can serve as guidelines for evaluating the need for intervention. The questions are repeated in the text
box below for review.
In keeping with the major themes of this book, developmental problems will be
explored along a continuum of severity. In this chapter, the focus is on mild variations
in behavior patterns that occur in children and adolescents in response to specific
stressors in their environment (school, family, neighborhood, or peers).
Difficulties coping with stressors may result in the development of an adjustment
disorder which can be accompanied by anxiety (fears, doubts, restlessness, separation
anxiety), depression (irritability, moodiness, sadness, withdrawal) or disruptive behaviors
(aggression, rule violations, truancy). Awareness of these typical adjustment problems
can provide an increased understanding of more serious disorders that will be discussed
in later chapters.
Six important questions to ask about the behavior pattern
1.
2.
3.
4.
5.
6.
Is it developmentally inappropriate?
Does it occur with greater frequency than anticipated?
Does it occur with greater severity than expected?
Is it causing concern for the safety of the child or others?
Is it causing significant dysfunction (school, home, peers)?
It is causing significant distress to the child or caregiver?
Although a transactional-bio-psycho-social approach recognizes that a child’s problems result from the interaction between all aspects of the child’s world, in some cases
environmental factors may play a more prominent role (family, peers), while child
characteristics may play a greater role in the development of other problems (genetics
and heritability).
Introduction to adjustment problems
Adjustment problems represent emotional or behavioral symptoms of distress in
response to a known stressor. The stressor can be a stressful event or situation, or
Adjustment Problems and Disorders in Childhood and Adolescence
137
involve a life change. The Diagnostic and Statistical Manual of Mental Disorders
(DSM) and the International Classification of Diseases (ICD) define adjustment disorders as clinically significant behaviors indicating either “marked distress” in excess of
what one would normally anticipate, or “significant impairment” in social or occupational (academic) functioning. Onset can manifest as early as one month after exposure
to the stressor, but must be evident within three months, and terminate within six
months. Adjustment disorders are considered to represent a temporary period of adaptation to the condition which caused the distress. Response to an acute event, such
as a change of schools, is usually more immediate and subsides within a few months.
However, if the stressor persists, and if there are other comorbid problems, then the
response may progress to other more severe disorders. According to the ICD, if symptoms persist beyond six months, then the diagnosis should be changed to reflect the
current clinical picture. The ICD includes culture shock, grief reaction, and hospitalization as possible sources of adjustment disorders. Although the current DSM distinguishes between bereavement (an expected response to the loss of a loved one) and
adjustment disorder, the recommendation is that in the revision, a subtype, “related
to bereavement,” be included as a special type of adjustment disorder with symptoms
enduring for at least 12 months following the death of a relative or close friend.
ICD and DSM: adjustment disorders and reactions
to stress
The DSM considers adjustment disorders as a separate category of disorders,
while the ICD clusters adjustment disorders under the major classification of
neurotic, stress-related, and somatoform disorders (F40–F48). Currently, the
DSM includes the stress disorders as part of the 10 anxiety disorders; however,
it has been proposed that the revision contain a separate category for trauma
and stress-related disorders.
Symptoms and prevalence of adjustment disorders
The nature of the response to the stressor may vary according to an individual’s cultural
background, developmental stage, temperament, and gender. Women are diagnosed
twice as frequently as men; however, boys and girls have an equal likelihood of being
diagnosed. Between 2% and 8% of children and adolescents will experience an adjustment disorder, and those living in high stress environments are vulnerable to increased
risk. For children, headache and stomachache are the most common somatic symptoms (Alfven, 2001), while feeling “mad” is the most common cognitive/emotional
response to a stressor (Sharrer & Ryan-Wenger, 1995). Compas, Connor-Smith,
Saltzman, Thomsen, and Wadsworth (2001) reviewed 63 studies concerning coping
with stress in childhood and adolescence. Results yielded four potential coping styles,
namely: two styles of engaged coping, such as active coping (cognitive decision making, problem solving), and seeking social support (emotion-focused support), and
two types of disengaged coping, such as distraction and avoidance (avoidance of
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negative emotions). Compas et al. (2001) concluded that children who use problemfocused and engaged coping tend to be better adjusted than those who use patterns
of disengaged coping.
Temperament, emotional reactivity, and response to stressors
In Chapter 2, temperament was described as a genetic trait that emerges early in
childhood and is characterized as an individual’s “general behavioral style that is relatively constant across situations.” Initially, Thomas and Chess (1977) described nine
traits, which were later consolidated into six traits by Rothbart and colleagues (Rothbart, Ahadi, & Evans, 2000; Rothbart & Bates, 2006), namely: general activity level
(intensity of responsiveness); fearful distress (attempts to withdraw from stimulation); irritable distress (negative emotionality; frustrating events produce restless,
fussy, and irritable responses); positive affect (positive disposition); attention span
persistence (focus on the task and avoidance of distractions); and rhythmicity or
adherence to routines (Rothbart, Ahadi, & Evans, 2000; Rothbart & Bates, 2006).
Rothbart’s model of temperament provides a unique distinction between fearful distress (triggered by fear) and irritable distress (triggered by frustration) based on the
nature of the stressor. Ultimately, Rothbart’s model clusters the traits into three major
components: emotion (fearful distress, irritable distress, positive affect), attention persistence and general activity level (Rothbart, 2003; Rothbart & Bates, 2006). These
characteristics of temperament have been found to be relatively stable from early
childhood to adulthood (Buss & Plomin, 1984).
Theorists have argued whether temperament is more “state-like” (certain types of
situations will evoke certain types of characteristics) or more “trait-like” (individuals’
response patterns are stable across different situations) (Kenny & Zautra, 2001).
However, although a case can be made for the influences of maturation and experience
on temperament (Henderson & Wachs, 2007; Rothbart & Bates, 2006), researchers
who have focused on differential consistency have found that individual differences
in patterns of responses become more pronounced with age, as responses influence
the trajectory of experience and patterns become more engrained over time (Rothbart
& Bates, 2006, pp. 124–127).
Differential consistency
In their discussion of differential consistency, Neppl et al. (2010) suggest that
with increased autonomy comes the ability to selectively choose social contexts
that are the best fit for one’s disposition (the cumulative continuity principle
of development). Over the course of time, these “person–environment transactions,” in which temperament influences social responses as well as social
responses influencing temperament, “reinforce and accentuate those very aspects
of temperament” (p. 387). As an example, Neppl et al. (2010) suggest that
if a toddler is outgoing and cheerful, responses in kind will likely reinforce
similar behaviors in the future (positive affectivity); however, if a toddler is
angry and upset, the likely responses that this toddler will receive will reinforce
negative affectivity.
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Five- and three-factor models of personality
What we think of as temperament in children, in its mature form is “personality”
in adulthood. There have been many theories of personality; however, trait theory is
closest to what we would relate to temperament traits. Historically, Cattell (1957) was
renowned for reducing a list of 18,000 words of traits into a 16-factor theory of personality (including such traits as warm, suspicious, tense, cheerful, and so on). Since
that time, researchers have continued to use more sophisticated types of factor analysis to reduce the list even further into five superordinate personality traits which have
come to be known as the “Big Five Factor” or the “Five-Factor Model” (Goldberg,
1993). Although the labels differ somewhat between the different variations on the
model, the most popular is the version by Costa and McCrae (1990) which includes
five traits (each on a continuum from most to least) represented by the acronym
OCEAN: openness to experience, conscientiousness, extroversion, agreeableness,
and neuroticism.
Recently, many researchers have found that Tellegan’s (1985) three-factor model,
or the “Big Three,” is a better fit for research because it has fewer factors and contains much of the same information. The three factors are: positive emotionality
(extroverted: energized and active); negative emotionality (threatened and distressed);
and constraint (high control, risk aversion, planning). Tellegan’s model, although
constructed for adults, has many of the same features evident in the discussion of
temperament, namely positive emotionality (surgency, approach, and pleasure), negative reactivity (negative affect response to fearful distress or irritable distress), and
effortful control (behavioral inhibition and attentional control).
Recently, Neppl et al. (2010) reported results of their longitudinal investigation
of the stability of temperament (using the three factors above: positive emotionality, negative emotionality, and constraint) for 273 families over the course of three
developmental periods: toddlerhood (two years), early childhood (three to five years),
and middle childhood (six to 10 years). Results revealed that there is stability and
continuity of temperament measured by all three factors of the “Big Three,” from
toddlerhood to middle childhood, despite the use of multiple raters, multiple instruments, and obvious differences in social contexts evident at different developmental
stages. Furthermore, not only were the dimensions of temperament consistent, stability increased with age for all three dimensions, such that stability quotients from early
childhood to middle childhood were higher than those measured from toddlerhood
to early childhood. Similar results achieved by Tackett, Krueger, Iacono, and McGue
(2008), comparing measures of the “Big Three” collected at middle childhood with
those obtained in late adolescence, provide comprehensive evidence of the stability of
the “Big Three” dimension across the lifespan from toddlerhood to late adolescence.
Effortful control (constraint)
According to Rothbart, the self-regulatory system of effortful control is one of the
most important aspects of temperament that influences a child’s ability to cope with
stressors. Effortful control is the voluntary ability to manage emotional (emotion
regulation) and behavioral responses (behavioral inhibition) to stressors by suppressing a dominant (prepotent) response in favor of a more adaptive response. Behavioral inhibition will be revisited in Chapter 8 in discussions of problems of attention persistence and executive functioning deficits in children with attention deficit
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hyperactivity disorder (ADHD). Children who have better effortful control are more
successful than peers with less effortful control, in areas of: task persistence, academic
achievement, social competency, social relatedness (give and take, sharing and cooperativeness), and moral maturity (Eisenberg, 2010; Kochanska & Aksan, 2006; Posner
& Rothbart, 2007).
Behavioral inhibition in high and low reactive temperaments
Kagan’s work with infants (Kagan & Snidman, 2004; Kagan & Fox, 2006) has demonstrated how infant reactivity at a very early age (four months) can predict later responses
to such stressful situations as stranger anxiety (seven to nine months of age). Kagan
and colleagues have determined that there are brain-based differences in how arousal
of the amygdale takes place in individuals who experience novel stimuli. Shy and
inhibited toddlers respond to stimulation with increased activation in the right frontal
lobe (associated with negative emotions, such as fear), while more outgoing and social
toddlers have less activation in the right, but more activation in the left frontal cortex
(associated with more pleasurable emotions). Researchers suggest that increased activity in the brains of inhibited children is associated with other physiological reactions
such as increases in heart rate, cortisol level, pupil dilation, and increased skin surface temperature, which are all responses associated with sympathetic nervous system
arousal and preparation for a fight or flight response (Kagan, 2007; Schmidt, Santesso,
Schulkin, & Segalowitz, 2007; Zimmerman & Stansbury, 2004).
How the brain registers emotions
Contrary to early speculation that all brain activity was filtered through the
cortex (the brain’s executive function) LeDoux (1996; Cain & LeDoux, 2008)
suggests that separate systems in the brain handle cognition versus emotional
responding, and that the fear circuit actually bypasses the cortex as messages go
directly from the sensory receptors to the thalamus which sends the message to
the amygdale. This would explain why our initial responses to fear can be so
powerful and lacking in logic.
Adjustment problems in early and middle childhood
Adjustment to school stressors
Does involvement in preschool programs place children at greater risk than children
who are reared in the home environment? This is a highly controversial question,
but one that needs to factor in the quality of preschool care versus the quality of
home care and any enrichment that the preschool program can provide that may be
instrumental in increasing the child’s exposure to positive learning experiences and
peer relationships. For children growing up in a high poverty and highly stressed
environment, an enriched and quality child care experience can have a protective
Adjustment Problems and Disorders in Childhood and Adolescence
141
effect, while for children living in an adequate environment, this experience can expand
opportunities for stimulating educational and social engagement with peers.
Transition to school Transition to school can be a stressful life event for some children
(Garmezy, Masten, & Tellegen, 1984). Schor (1986) found that access to public
health services for complaints of headaches, stomachaches, and body pains peaked for
children and youth during two key periods: transition to elementary school (six years
of age) and entry into junior high school (12 years of age). Recently, Turner-Cobb,
Rixon, and Jessop (2008) studied stress resulting from the transition to school for
105 four-year-old children who were about to enter primary school for the first time
in the United Kingdom. Parents collected morning and evening saliva samples: four
to six months before the children were to begin attending school; two weeks into
the first term; and at six and 12 months follow-up. Assessment of the anticipation,
transition, and adaptation to school revealed that cortisol levels were considerably
higher in the anticipatory stage than levels collected at transition or six-month followup. Furthermore, children with poor effortful control exhibited higher cortisol levels
at transition, while those who experienced social isolation in the first six months
exhibited higher cortisol levels at follow-up.
The hypothalamic–pituitary–adrenal (HPA) pathway
Recall that under stress, the hypothalamus activates the pituitary gland which
in turn causes the adrenal glands to release corticosteroids, a group of stress
hormones, such as cortisol, into the system. Cortisol mobilizes vital organs to
respond to increased stress or pending threat. Cortisol levels can be analyzed
through saliva samples.
Role of temperament
Overcontrolled behaviors There is increasing interest in the adjustment problems
of overly shy and inhibited children (Kagan, 1997; Kagan & Fox, 2006). Extremely shy
children have a lower threshold for arousal of the amygdale (which regulates emotions
and the fear response), and evidence higher cortisol levels, increased heart rate, and
greater right frontal activation (Fox, Henderson, Rubin, Calkins, & Schmidt, 2001).
Shy and reticent children are more likely to be exposed to peer rejection, exclusion,
loneliness, and victimization in the early school years (Coplan, Closson, & Arbeau,
2007; Gazelle & Ladd, 2003). At least one study reported that some teachers believe
shyness to have as much of a negative impact on social and school adjustment as
aggression (Arbeau & Coplan, 2007).
Children who respond to situations with high emotional reactivity, and have low
effortful control or low attentional control, have fewer strategies for adapting to
anxiety-provoking situations and are at increased risk for developing internalizing disorders (Eisenberg et al., 1997; Anthony, Lonigan, Hooe, & Phillips, 2002). Children high in negative emotionality, or trait negative affect (Watson & Clark,
1984), demonstrate characteristics of nervousness, guilt, self-dissatisfaction, sense of
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rejection and sadness, tension, anger, and frustration resulting from high levels of
arousal of their motor, affective, and sensory systems. As a result, preschoolers can feel
overwhelmed, fearful, and distressed, which can predict the development of internalizing behaviors in later childhood and adolescence (Mun, Fitzgerald, Von Eye, Puttler,
& Zucker, 2001; Rothbart, Ahadi, Hersey, & Fisher, 2001). Preschoolers who are
overly shy and inhibited have higher cortisol levels, and poorer peer relations (Eisenberg et al., 1993; Gunnar, Tout, de Haan, Pierce, & Stansbury, 1997). Researchers
have found that very shy preschoolers who develop effortful or attentional control
as they mature are less likely to remain shy and inhibited over the course of time
(Henderson, Fox, & Rubin, 2001). However, if these children are in high-risk environments (negative parent traits; low family cohesion) and do not develop increased
ability for attentional control and effortful control, then internalizing symptoms can
remain stable into later childhood and adolescence.
Undercontrolled behaviors Aggressive behaviors contribute significantly to school
adjustment problems. The ability to detect aggressive behaviors in infants as young
as five months of age has prompted researchers to suggest that aggression can be
innate (Tremblay, LeMarquand, & Vitaro, 1999). The nature, severity, and intensity
of aggressive responses can vary widely, with some children demonstrating aggression
at an earlier age (early starters).
Hot- or cold-blooded?
Aggressive responses can be proactive or cold-blooded (planned and premeditated), or they can be reactive and hot-blooded (Dodge, Lochman, Harnish,
Bates, & Pettit, 1997).
In Chapter 9, the focus will be on the more serious and stable patterns of aggressive
and defiant behaviors that can develop in children (oppositional defiant disorder;
ODD) and youth (conduct disorder; CD) and the nature of interventions to assist in
treating these disorders.
Children who exhibit undercontrolled behaviors (difficult temperament, with
hyperactivity and poor ability to inhibit responses) are at the greatest risk for negative outcomes, including school adjustment problems. Preschoolers who demonstrate
“exuberance” or surgency (Ahadi, Rothbart, & Ye, 1993) often demonstrate high
activity levels and traits of impulsivity, and seek out novel and sensational (pleasurable) experiences. Because these exuberant children’s behaviors can escalate out of
control, they are at increased risk for peer rejection, and for developing more serious externalizing problems, such as disruptive behavior disorders (Rimm-Kaufman
et al., 2002). However, similar to their peers who are at risk for developing internalizing problems, researchers have found that if exuberant children develop greater
effortful control, then the risk of developing externalizing problems dissipates (Rubin,
Coplan, Fox, & Calkins, 1995).
Other school-related factors Other problems that can cause school adjustment difficulties include: comorbid problems (learning disabilities, emotional and social difficulties), child perceptions of teacher support, and a chaotic school environment.
Adjustment Problems and Disorders in Childhood and Adolescence
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Comorbid problems Children who have pre-existing learning, emotional, or social
problems are at increased risk for school adjustment problems. Adding additional
risks can have a multiplier effect (Sameroff & Fiese, 2000). Rutter (1979) found that
children exposed to two risk factors predicted a fourfold increase in psychopathology,
while exposure to four risk factors increased the chances tenfold. Although children
with the inattentive type of ADHD are less severely impaired than those with both
inattentive and hyperactive-impulsive symptoms, they demonstrate more comorbid
internalizing disorders, learning disabilities, and academic problems, and are two to
five times more likely to be referred for speech and language problems (Weiss, Worling,
& Wasdell, 2003).
Teacher support At least one study found that two of the most powerful stressors for school children are assessments and teacher psychological abuse. Piekarska
(2000) investigated the causes of stress for 271 children enrolled in the Polish public
school system. The researcher concluded that teachers’ psychological abuse caused
stress and anxiety in the children, who developed survival-coping strategies that were
not only destructive to their school achievements but also to their psychological
well-being.
On a more positive note!
Gruman, Harachi, Abbott, Catalano, and Fleming (2008) found that teacher
support had a positive influence on children who had mobility issues (multiple
school moves).
Gruman et al. (2008) studied the potential risk from multiple school moves in
second-through fifth-grade children (N = 1,003). School changes predicted declines
in academic performance and classroom participation; however, these effects were
moderated by peer acceptance and teacher support, which increased positive attitudes
toward school among children who had experienced the most school changes.
Chaos in the school environment Chaos in the school environment, which can
contribute to the development of stress and interfere with learning in children, can
take many forms, including “high levels of noise, crowding, confusion, instability of
school or residence, changes in adult caregivers or friends, and low level of structure and regularity of routines” (Maxwell, 2010, p. 83). Although there are individual differences in children’s sensitivity to external noise, the majority of children
attending schools located in high traffic areas (near flight paths, subways, or train
stations) report the noise as “annoying” (Hygge, Evans, & Bullinger, 2002), and
interfering with their ability to do their work or concentrate (Haines & Stansfeld,
2000; Simon, 2005). Classroom crowding has been related to increases in disruptive
behaviors (Maxwell, 2003) and lower academic achievement (Evans, Lepore, Shejwal, & Palsane, 1998). Ehrenberg, Brewer, Gamoran, and Willms (2001) demonstrated positive academic outcomes for elementary school children who were randomly
assigned to smaller classes with 13 to 17 children, compared to peers assigned to
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larger classrooms containing 22 to 25 children. Classrooms are visually complex settings and can become very “busy” with visual displays (such as posters or art) that
can be distracting to young learners, although this is an area that has not received
much research interest to date (Maxwell, 2003). Since studies have demonstrated
how noise and crowding can impede the learning process for children in general, it
would not be surprising to find that a chaotic classroom would interfere with learning
and add to the challenges that children with disabilities and special needs face in the
learning environment.
Adjustment to family stressors
Parental stress and family conflict Essex, Klein, and Lakin (2002) found that maternal stress beginning in infancy was the most potent predictor of elevated cortisol levels
in children. Furthermore, preschoolers with high cortisol levels exhibited more mental
health symptoms in first grade than their peers. In their sample of seven- to 10-yearold children, Stocker and Youngblade (1999) found that increased marital conflict
was related to more hostile parent–child interactions (with both mothers and fathers),
more conflicted sibling relationships, and difficulties relating to peers. Persistent marital conflict has been associated with a number of negative child outcomes, including
conduct problems, anxiety, and aggression (Grych & Fincham, 1990). High levels
of stress or marital conflict may be evident in preschool children’s negative play with
peers, anxiety concerning parent welfare, and increased risk for behavioral problems
(Frosch & Mangelsdorf, 2001).
Can the termination of marriage have benefits?
Morrison and Coiro (1999) found that living in a two-parent family with a high
degree of marital conflict can be more problematic for children than the actual
termination of the marriage following high degrees of conflict.
Recently, Crawford, Schrock, and Woodruff-Borden (2011) investigated the interaction between child temperament (negative affect and effortful control) and environmental factors (maternal negative affect and family functioning) in the prediction of
internalizing symptoms in young children. The results of their study revealed a direct
and indirect pathway to internalizing disorders. In the direct model, child negative
affect and family functioning predicted childhood internalizing symptoms. In the indirect model, effortful control is linked to internalizing by way of the impact that it has on
family functioning. Children high in negative affect often respond to stressful situations
by withdrawal and avoidance; a pattern that only serves to reinforce the maintenance of
their anxiety symptoms. Crawford et al. (2011) propose that “maternal negative affect
plays a meditational role with child effortful control contributing to the overall tenor
of the family environment” (p. 60). Since mothers with negative affect are less positive
and sensitive in their parenting practices, it is possible that they exacerbate their child’s
Adjustment Problems and Disorders in Childhood and Adolescence
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symptoms of negative affect (anxiety, fears, depression, withdrawal, somatic complaints, and social problems).
Chaos in the home Ackerman and Brown (2010) discuss several aspects of physical
(noise, crowding, order, predictability of family routines) and psychosocial (family
stability, parental mental illness or well-being, employment schedules) chaos in
the home that can impact cognitive and social outcomes for early and middle
childhood. Although family income (socio-economic status; SES) can influence
chaos, some studies suggest that some factors like family relocations, when controlled
for SES, still can have a negative influence on academic achievement (Adam, 2004).
Unpredictability and lack of structure in the home can influence children’s motivation
and their feelings of self-worth, and can be associated with negative outcomes for
children in a number of areas, including: behavior regulation (attention, working
memory), reading, and parent–child communication (Evans, Gonnella, Marcynyszyn,
Gentile, & Salpekar, 2005).
The ramifications of family instability can be far-reaching, and can impact development in a number of ways, including teacher ratings of popularity and social competency, as well as child self-ratings of loneliness (Hertzman, 2010). According to results
from the Canadian National Longitudinal Survey of Children and Youth (NLSCY)
conducted in the late 1990s, 41% of preschool children had experienced a residential
move, and “behavioural and receptive language delays in development by age 4 or
5 rose consistently with the number of residential moves experienced by the child”
(Hertzman, 2010, p. 114).
Divorce and separation Divorce may be harder on younger children compared to
older children, since they are unable to cognitively process the fact that the marital breakup was not their fault (Hetherington & Stanley-Hagan, 1999). Feelings of
self-blame are the most common responses that young children experience (threeand-a-half to six years of age) in response to a marital split (Wallerstein & Kelly,
1982). Divorce can be preceded by a history of conflict, and often the conflict continues throughout the process, as issues of custody and access enter into the fray. For
school-age children, the outcome will be moderated by the severity of the conflict and
how disputes are managed (Hetherington & Kelly, 2002). Parenting practices may
also be inconsistent during a tumultuous divorce and parents may vacillate between
being controlling and intrusive, or lacking in discipline (Madden-Derdich & Leonard,
2001). When parents are cooperative and peaceful, children have much better outcomes, regardless of whether the custody arrangement involves joint or sole custody
(Parke & Buriel, 1998).
Gender effects when security is threatened by a divorce
Boys respond to the perceived threat inherent in a divorce with increased aggressive and assertive responses, while girls become engaged in futile attempts to
reunite the parents, resulting in feelings of anxiety and depression (Davies &
Lindsay, 2001).
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Siblings: allies or rivals
Sibling conflict Siblings can experience elements of positive as well as negative
feelings towards each other. However, compared to peers, emotions surrounding
siblings tend to have a more intense and enduring impact (Buhrmester & Furman,
1990). Studies suggest less perceived sibling conflict among children under the age of
eight, since social comparisons are outside the realm of their cognitive capacity, and
on the surface, primary school children seem to have less conflict with siblings than
peers. Yet when the amount of time spent together is taken into consideration, the
rate of conflict is higher for siblings (DeHart, 1999).
Although conflict and disagreements can be a normal part of sibling relationships
(Shantz & Hobart, 1989), persistent and severe hostility between siblings can contribute to internalizing problems in elementary school children, such as depressed
mood, loneliness, and low self-esteem (Stocker, 1994), or externalizing problems and
deviant behaviors (Stocker, Burwell, & Briggs, 2002), especially if parental rejection
is also evident (Garcia, Shaw, Winslow, & Yaggi, 2000). With respect to externalizing
problems, sibling conflict at an early age has been linked to hostility and aggression in
five-year-olds (Garcia et al., 2000), and later on in adolescence (Kim, Hetherington,
& Reiss, 1999).
Sibling rivalry increases in middle childhood, especially if parents compare accomplishments or characteristics among children resulting in the “lesser” child feeling
resentful, which can impact future adjustment (Dunn, 2004). Sibling rivalry is often
most intense when the goal is to obtain parental attention and approval, and siblings
are both males, close in age, or if the elder sibling is a male; the situation intensifies if
there is marital conflict, or family stress due to financial problems (Dunn, Slomkowski,
& Beardsall, 1994; Jenkins, Rasbash, & O’Connor, 2003).
Siblings and the ICD
Although it is not uncommon for siblings to have conflict, the ICD recognizes
sibling rivalry disorder (F93.3), under the category of emotional disorders with
onset specific to childhood. The disorder is characterized by a combination of:
a. evidence of sibling rivalry and/or jealousy;
b. onset following the birth of a younger sibling (usually the child next in age
is affected);
c. marked emotional disturbance associated with psychosocial problems.
Associated features may include: competitiveness for parental attention, high
degree of negative feelings, and possible malicious intent to undermine the
sibling, as well as lack of positive regard and unwillingness to share. Frequently,
the child may demonstrate regressive behaviors, such as reverting to bottle
feeding, and baby talk. There is no comparable disorder in the DSM.
Sibling support Despite the possibility of intense negative emotions, siblings can
also provide a sense of mutual support to each other in times of family difficulties, such
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147
as parental conflict or divorce (Jenkins, 1992), or when there is a lack of peer support;
in these times children will treat older siblings as surrogate attachment figures in the
absence of the parent, seeking comfort when distressed (Seibert & Kerns, 2009).
Older siblings can gain confidence in their leadership skills or responsibility when
caring for younger siblings (Marvinney, 1988) or gain experience in teaching and
nurturing others (Eisenberg & Fabes, 1998).
Sisters report more intimacy at all age levels, while maternal acceptance has been
identified as a significant correlate of peer intimacy, regardless of gender, at all ages
(Kim, McHale, Osgood, & Crouter, 2006). Regardless of the nature of the sibling
relationship, it tends to remain stable from early to middle childhood (Buhrmester &
Furman, 1990).
Adjustment to environmental stressors
In Bronfenbrenner’s bioecological model (1979, 2001), there are four primary influences that can be found in the child’s immediate environment: family (including the
home, parents, and siblings), schools (including preschool and elementary or primary
school settings, teachers, classrooms); the neighborhood (safe versus violent; access to
leisure activities, playgrounds), and peers (friends and playmates). In this section, the
focus is on stressors existing in the young child’s neighborhood or peer relationships.
Neighborhood disadvantage All children who grow up in impoverished environments
do not develop problem behaviors; however, low SES at an early age can be a predictor
of delinquency in adolescence (Brooks-Gunn & Duncan, 1997). The earlier the onset
of risk factors, such as poor peer relationships, neighborhood ecology, or academic
achievement, the stronger the predictor of problem behaviors in the future (Appleyard,
Egeland, van Dulmen, & Sroufe, 2005). At-risk toddlers who do not have the benefit
of quality child care are at increased risk for school drop-out and committing juvenile
offences as adolescents (Harlow, 2002; Schweinhart, Barnes, & Weikart, 1993). Duncan, Brooks-Gunn, and Klebanov (1994) found that having more low-income neighbors put five-year-olds at increased risk for externalizing behaviors (temper tantrums,
destructive behaviors), even when controlling for family income, SES, and other family variables. Exposure to negative peer group influences, and attending schools and
preschools of lower quality (e.g., those with lower quality resources, or higher pupil–
teacher ratios), may also predispose young children to these risks, contributing to an
overall negative neighborhood effect (McLoyd, 1998). Children living in impoverished neighborhoods often experience barriers to involvement in organized recreation
due to lack of financial support and neighborhood resources (Jones & Offord, 1989).
Life transitions, stressful life events, and exposure to neighborhood violence at a young
age can predispose a child to aggressive behavior in later years (Attar, Guerra, &
Tolan, 1994).
Peer relationships Children’s peer relations can be instrumental in shaping the course
of social and emotional development (Asher & Coie, 1990). However, children can
experience the stress of poor peer relationships due to a number of different reasons,
including the development of inadequate social skills as a result of externalizing problems (aggression), internalizing problems (shyness, anxiety, and social withdrawal),
impulsivity (attention deficit disorder), or other comorbid disorders (such as learning disabilities). Children who are aggressive and are prone to interpret ambiguous
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behaviors of peers as having hostile intent (hostile attribution bias) are often rejected
by peers (Dodge, Price, Bachorowski, & Newman, 1990). Children who are shy
demonstrate a wariness and anxiety concerning social situations due to their fear of
being evaluated negatively by peers (Coplan & Armer, 2007). As a result, although
these children often desire to interact with peers, they are simultaneously inhibited by
their social fear and anxiety (Coplan, Prakash, O’Neil, & Armer, 2004). As previously
discussed, shyness and being inhibited can result from underlying biological factors
(Kagan, 1997), or overprotective (or over-involved) parenting (Rubin, Burgess, &
Hastings, 2002). Children who have attention deficit hyperactivity disorder (ADHD)
often experience problems with social adaptation, and approximately 50% of children
diagnosed with ADHD will experience difficulties in their relationships with peers
(Pelham & Bender, 1982).
Social difficulties are so prominent among individuals with specific learning disabilities that it has been argued that social disability should be included in the definition
proper (Rourke, Young, & Leenaars, 1989). Stone and La Greca (1990) conducted a
sociometric survey in a sample of children in the fourth through sixth grades. Based
on the responses, children were classified into categories of popular, rejected, and
neglected. Children with specific learning disabilities were overly represented in the
rejected (28%) and neglected (26%) categories, relative to their peers.
Sociometric surveys of peer status
Since the 1950s, researchers have used sociometric surveys to categorize
children’s peer relationships. A study by Vasa, Maag, Torrey, and Kramer
(1994) indicated that 41% of teachers used the surveys to better understand
classroom dynamics. Initially, only social acceptance (peer nomination as a
friend or preferred play-mate) was indexed due to ethical concerns about having
children label disliked peers. Since that time, the sociometric survey has evolved
into a two-dimensional survey that classifies peer status (social likability) and
social impact and has been found to have virtually no negative influence on
peer responders (Bell-Dolan & Wessler, 1994; Mayeux, Underwood, & Risser,
2007).
Newcomb, Bukowski, and Pattee (1993) conducted a meta-analysis of 41 studies
that employed sociometric techniques to obtain evaluations of peer status and found
the following traits associated with each status:
Popular status When compared to their “average” peers, popular children evidence
higher levels of sociability and cognitive abilities, greater problem-solving skills, more
social traits. and lower levels of aggression and withdrawal. They also have the ability
to maintain friendships over time and are often sought after as preferred play-mates
by their peers.
Rejected status Aggressive children who are less skilled cognitively and socially
are often rejected by peers. Furthermore, rejected children often express aggression
Adjustment Problems and Disorders in Childhood and Adolescence
149
physically and in negative behaviors that are disruptive. Rejected children may also
experience depression and anxiety resulting from their stressful peer relations.
Neglected status Neglected children have low social impact and are less aggressive
and social than average children. Although they may share traits of their “average”
peers, their low visibility may result in them not being selected in favor of the more
popular peers.
Controversial status Children in this group have a mix of traits from the popular and
rejected categories. Controversial children share elevated levels of aggression similar
to their rejected peers (in fact, in some studies they demonstrate more aggression than
rejected children), but have better-developed cognitive and social skills and are more
socially aware than the rejected children.
Adjustment problems in adolescence
Adjustment to school stressors
School transitions Although students begin secondary school with moderate interest, there is a significant decline in interest, motivation, and academic performance
across adolescence (Barber & Olsen, 2004). Declines may be related to changes in the
school setting and expectations that accompany the transition from primary school to
secondary school, as smaller settings with close teacher contact and direct supervision
are replaced by larger classes, multiple teachers, higher expectations, and less guidance
and supervision (Seidman, Aber, & French, 2004). By secondary school, it has been
reported that half of students (between 40% and 60%) become increasingly and chronically disengaged from school (Klem & Connell, 2004), and 30% of students engage
in behaviors that are high-risk, and not conducive to academic performance (Eaton
et al., 2008). Furthermore, as the number of life changes increase (school transition,
pubertal development, onset of dating, residential moves, family conflict), academic
performance decreases accordingly (de Bruyn, 2005; Seidman, Lambert, Allen, &
Aber, 2003).
Academic interest and gender
Although Dotterer, McHale, and Crouter (2009) found an overall decline in
interest from late school age (10–11 years) to secondary school (13–14 years),
girls reported significantly higher levels of interest at the beginning and end of
secondary school. This finding is interesting, given the significant decreases in
male college enrolment figures from the 1970s (55%) to recent times (45%)
(King, 2006).
While transitions to secondary school can be stressful, Rothon et al. (2009) found
that graduation can be equally stressful, especially for those with poor academic
performance. Rothon and colleagues found that students attending East London
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secondary schools who scored high on a distress measure at 13 to 14 years of age
performed the worst on the General Certificate of Secondary Education (GCSE),
administered at the end of compulsory education (16 years of age).
In the United States, transition from high school has taken on greater significance
in federal education law, improving services for students transitioning from public
education to vocational programs or the community work force. In 1997, it became
mandatory to have a student’s Individualized Educational Program (IEP) include such
transition plans, with respect to adult living objectives. Transition plans are now an
integral part of the IEP (IDEA, 2004).
The transition to secondary school may also represent a transition to a larger school.
Studies have shown that student absenteeism is lower in smaller versus larger secondary
schools (Finn & Voelkl, 1993) where there is more engagement in prosocial behaviors
and extracurricular activities (Moore & Lackney, 1993). Youth with close and positive
friendships often will sustain these friendships in times of transition, which may ease
their adjustment to the new school both socially and academically (Aikins, Bierman,
& Parker, 2005).
Role of affect regulation and comorbidity Faced with a stressful event, arousal can
be seen as a two-stage process involving: reactivity (increased physiological arousal)
and recovery (post-stress response of decreased arousal) (Linden, Earle, Gerin, &
Christenfeld, 1997). Different parts of the autonomic nervous system (ANS) are
involved in the reactivity phase (sympathetic nervous system) and the recovery phase
(parasympathetic nervous system). The sympathetic nervous system appraises the
level of stress and mobilizes the internal arousal system (“fight or flight” response),
while the parasympathetic system returns responses to normal (Porges, 2003). Weak
recovery by the parasympathetic system and an overly sensitive or overactive sympathetic system can result in strong emotions of anger and avoidance (Beauchaine,
Gatzke-Kopp, & Mead, 2007). Developmentally, as affect regulation becomes more
controlled, individuals acquire positive skills to cope with stressful circumstances.
However, youth with externalizing problems or internalizing problems often experience more problems with affect regulation in difficult circumstances.
In their study of students enrolled in two secondary schools in the US mid-west,
Martyn-Nemeth, Penckofer, Gulanick, Velsosr-Friedrich, and Bryant (2009) found
that stress and low self-esteem were related to both avoidant coping patterns and
depressed mood. Furthermore, the combined effect of low self-esteem and avoidant
coping were also related to unhealthy eating behaviors (dietary restraint, or overconsumption).
Parenting and affect regulation
Having a secure parent relationship facilitated emotion regulation and recovery
after exposure to a stressful task for youth with externalizing problems, but not
for those with internalizing problems. Willemen, Schuengel, and Koot (2009)
suggest that “frustration and irritability” demonstrated by youth with externalizing problems was a much easier response for parents to recognize than
less obvious responses (such as guilt or shame) that youth with internalizing
problems may be experiencing.
Adjustment Problems and Disorders in Childhood and Adolescence
151
Emotion regulation and the adolescent brain Recall that in situations of heightened emotionality, adolescents are more likely to make impulsive decisions and engage
in risky behaviors. According to Casey, Jones, and Somerville (2011), during adolescence increased production of cortical dopamine levels, and an imbalance between
heightened awareness of emotional cues (overactivation of the subcortical regions of
the brain), in the presence of immaturity in cognitive control (the prefrontal cortex
responsible for planning ability and logical problem solving) place the adolescent at
increased risk for sensation seeking, impulsivity, and risky decisions.
Adjustment to family stressors
Parenting practices and family cohesion There is increased risk for negative mental
health outcomes for cumulative risks rather than any single risk factor (Gutman,
Sameroff, & Eccles, 2002; Prelow & Loukas, 2003). In a large community sample of adolescents, Roberts, Roberts, and Chan (2009) found that 7.5% of their
population developed the first episode of a psychiatric disorder during adolescence.
Experiencing two or more stressors was a significant predictor of a clinical diagnosis,
while adverse family circumstances (poor family satisfaction, high maternal stress, and
stressful relations with mother, father, or both parents) predicted the incidence of
being diagnosed with a disorder for every disorder examined in the study, including: anxiety, mood, attention deficit hyperactivity disorder (ADHD), disruptive, and
substance abuse/dependence disorders. Adolescents who live with the stress of family conflict are prone to chronic emotional arousal and increased reactivity to other
stressful events (Repetti, Taylor, & Seeman, 2002), and are at increased risk of feeling
helpless to control their environment (Chorpita & Barlow, 1998).
Family instability can cause stress due to disruptions of normal family routines,
alteration of the family constellation, or frequent family relocations. Adam and ChaseLonsdale (2002) found that adolescent adjustment problems increased in proportion
to the number of residential moves experienced, even after controlling for demographic variables, such as SES. Researchers suggest that feelings of insecurity, disconnection from social relationships, and stress reactivity may contribute to adjustment
problems (Cummings, Davies, & Campbell, 2000; Pribesh & Downey, 1999).
Studies have also examined the role of attachment and parenting style as moderators of stress in adolescents. In a recent longitudinal study of community-based
adolescents, Dick et al. (2011) investigated gene–environment interaction and the
biological and environmental contributors to adolescent externalizing behaviors. The
results revealed that the association between genotype (CHRM2; cholinergic muscarinic 2 receptor) and externalizing behavior was the strongest in environments with
low parent monitoring and weakest in environments with high parent monitoring.
In another study, Lee and Hankin (2009) found that anxious and avoidant attachment patterns predicted anxiety and depression in youth, while anxious attachment
mediated by low self-esteem and dysfunctional attitudes also predicted internalizing
symptoms for this group.
Siblings Sibling support, intimacy, and companionship are lower in adolescence,
compared with middle childhood, due to the increasing significance of peer group
support (Buhrmester & Furman, 1990). In a longitudinal prospective design, Stocker,
Burwell, and Briggs (2002) monitored sibling conflict from middle childhood (seven
to nine years of age) to early adolescence (11 to 12 years of age) and found sibling
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conflict was predictive of anxiety, depressed mood, and delinquent behaviors in early
adolescence. In their study of sibling relationships between younger and older sisters,
Slomkowski, Rende, Conger, Simons, and Conger (2001) found older sisters’ hostility was predictive of the younger sister developing subsequent delinquent behaviors.
Bank, Patterson, and Reid (1996) found sibling conflict predicted later adjustment
problems in adolescence and adulthood. Siblings who have a warm, supportive relationship in adolescence also tend to have more gratifying friendships with peers (Yeh &
Lempers, 2004).
Sibling conflict and adjustment problems
Stocker, Burwell, and Briggs (2002) suggest several explanations for the negative
influence of sibling conflict, including social learning theory (observation and
imitation of externalizing behaviors), negative attribution style (inescapable
conflict and feelings of self-blame resulting in internalizing behaviors), and
social cognition (living in a conflicted environment providing little opportunity to interpret normative social cues, resulting in the hostile attribution
bias). Younger children may be more strongly influenced by conflict with older
siblings, since the older siblings may dominate the relationship and engage the
younger siblings in deviancy training, introducing them to their deviant peers
(Rowe & Gully, 1992).
Adjustment to environmental stressors
Peer relationships A supportive network of peers can provide a protective influence
against negative outcomes (Criss, Pettit, Bates, Dodge, & Lapp, 2002). A failure
to meet socio-developmental milestones in forming healthy peer relationships can
lead to externalizing or internalizing problems based on one of two possible trajectories. Oland and Shaw (2005) suggest that children may develop internalizing
symptoms (highly anxious and inhibited responses) leading to avoidance of involvement with peers and lack of healthy peer relationships; or develop externalizing symptoms (impulsivity, poor emotional control, idealized self-concept, callous unemotional
traits) leading to a failure to develop normal reciprocal and empathic relationships.
Youth with internalizing symptoms who eventually establish positive peer relationships have far better outcomes than those who cannot (Gazelle & Ladd, 2003), since
social avoidance leads to progressive social impairment and reduced social acceptance
(Ginsburg, La Greca, & Silverman, 1998). Youth with externalizing problems lack the
emotion regulation and self-monitoring necessary to establish successful social interactions and are often rejected by peers (Keiley, Lofthouse, Bates, Dodge, & Petit,
2003), placing them at increased risk for linking up with similar peers (Lahey, Waldman, & McBurnett, 1999). Deviant peer affiliations have been linked to increased risk
for suicide (Fergusson, Beautrais, & Horwood, 2003), substance use, and antisocial
behaviors (Beautrais, 1999).
Adolescent girls who feel friendless and isolated are at twice the risk for suicide
ideation (Pfeffer, 2000), while support group cohesion serves as a protective factor for
Adjustment Problems and Disorders in Childhood and Adolescence
153
depression and suicide. For boys, protection from suicide risk was found in activitybased groups rather than peer friendships (Bearman & Moody, 2004).
Can you be a stress magnet?
The stress-generation hypothesis suggests that stressful interpersonal life
events can be generated by dysfunctional behaviors and attitudes (Hammen,
2006).
Other environmental stressors A negative cognitive style (Safford, Alloy, Abramson,
& Crossfield, 2007), poor interpersonal problem solving (Davila, Hammen, Burge,
Paley, & Daley, 1995), excessive reassurance seeking (Potthoff, Holahan, & Joiner,
1995), and avoidant coping (Holahan, Moos, Holahan, Brennan, & Schutte, 2005)
are all mechanisms that can increase the risk for generating stressful interpersonal life
events. Harkness and Stewart (2009) found that adolescents’ scores on a depression
inventory collected at Time 1 predicted higher rates of stressful interpersonal events
experienced within the next 12-month period.
McLaughlin and Hatzenbuehler (2009) examined the role of stressful life events
in the development of anxiety sensitivity in 1065 adolescents in a community sample.
Anxiety sensitivity is a “fear of symptoms, including bodily sensations, which results
from beliefs about the harmful, social, psychological, or physiological consequences
of such symptoms” (McLaughlin & Hatzenbuehler, 2009, p. 659). This lowered
threshold for anxious responding has been linked to panic attacks, trait anxiety, and
anxiety disorders in children and adolescents (Pollock et al., 2002). Stress and experiencing of stressful life events has been shown to impact child and adolescent mental
health in negative ways (Grant, Compas, Thurm, & McMahon, 2004). Stressful life
events can contribute to increases in anxiety sensitivity, especially if the stressors are
health-related (fear of disease) or related to family discord; however, anxiety sensitivity
predicted anxiety but not depressive symptoms seven months later (McLaughlin &
Hatzenbuehler, 2009).
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7
Early Onset Problems: Preschool
and Primary School
Chapter preview and learning objectives
Neurodevelopmental disorders and disabilities
Intellectual developmental disorder/disability (IDD)
Clinical description: nature and course
The nature of IDD
Developmental and associated features
Subtypes and prevalence: etiology of chromosomal
abnormalities/genetic origins
Subtypes and prevalence: etiology of environmental origins
Assessment
Early intervention and prevention
Autism spectrum disorders (pervasive developmental disorders)
ASD: nature and course
Asperger disorder (AD)
ASD: prevalence rates and etiology
ASD: assessment
ASD: treatment and intervention
Childhood disintegrative disorder (CDD)
Children with speech, language, and communication problems
Speech and language impairments: nature of disorders
Late language emergence (LLE)
Specific language impairment (SLI)
Social communication disorder (SCD)
Issues of fluency and voice
Prevalence rates and etiology
Assessment and treatment
Other early onset childhood disorders
Eating and feeding disorders of infancy and early childhood
Selective mutism (SM)
References
Clinical and Educational Child Psychology, First Edition. Linda Wilmshurst.
© 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.
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Chapter preview and learning objectives
In this chapter, three neurodevelopmental disorders will be discussed, including intellectual developmental disabilities (IDD), autism spectrum disorders (ASD, formerly
known as pervasive developmental disorders (PDD)), and communication disorders.
Our notion of IDD (formerly mental retardation) has evolved over time, and is currently conceptualized as a condition of subnormal intellectual capacity manifesting
during the developmental period, accompanied by impairments in adaptive functioning. The change in terminology from mental retardation to IDD is in keeping with
how the disability is currently conceptualized. The American Association of Mental
Retardation (AAMR) recently changed its name to the American Association of Intellectual and Developmental Disability (AAIDD; www.aamr.org) in keeping with this
movement.
Children with ASD evidence qualitative impairments in social reciprocity and communication skills, and engage in a restricted range of activities often involving nonfunctional and stereotypical routines. Many with ASD also have comorbid intellectual
disabilities.
While not all children with language impairments are diagnosed with IDD or ASD,
many children with these developmental disorders also evidence some degree of language impairment. Within this chapter, the essential features of developmental language impairments will be discussed, as they relate to difficulties with expressive,
receptive, and social communication.
In addition to the neurodevelopmental disorders mentioned above, the chapter
will also focus on two other disorders that have early onset: feeding disorders and
selective mutism. While some children are “fussy” eaters, other children demonstrate
food refusal, a predominant symptom of a condition known as “failure to thrive”
which can result in significant health risks. Children who are diagnosed with selective
mutism refuse to speak in public, although their speech is often otherwise unimpaired.
Currently, there is much controversy regarding how best to conceptualize selective
mutism.
This chapter will provide increased understanding of:
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the role of intellectual and adaptive functioning in meeting criteria for intellectual
disabilities;
the difference between developmental delay and developmental deficit;
the difference between a general learning disability and a specific learning disability;
the nature and range of autism spectrum disorders;
the multi-faceted nature of language impairments, and how these are related to
other developmental disorders;
the nature and characteristics of other early onset problems, such as feeding disorders and selective mutism.
Neurodevelopmental disorders and disabilities
This chapter reviews three neurodevelopmental disorders: intellectual developmental disability, autism spectrum disorders, and communication disorders. Two other
neurodevelopmental disorders, attention deficit hyperactivity disorder (ADHD) and
the specific learning disabilities, will be discussed in the next chapter.
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Intellectual developmental disorder/disability (IDD)
Clinical description: nature and course
Introduction Understanding (IDD) requires an appreciation of how intelligence
relates to mental age and an awareness of differences between specific or global delays
in development (developmental delay) versus life-long deficits in the ability to
reason and learn, resulting in limitations in adaptive functioning.
Idiocy versus madness
In 1838, Jean Esquirol (1772–1840) devoted a large section of his book on
mental health to the topic of “idiocy.” Esquirol was the first to articulate the
difference between “idiots” who never developed their mental capacity and the
“mentally deranged” who once had mental capacity, but lost it (Sattler, 2001,
p. 129).
Global developmental delay The term global developmental delay captures the
concept of development as a continuum, and individual differences in the rate of
acquiring expected skills in areas such as language, motor, or cognitive and adaptive
functioning. Children suspected of having significant delays in these areas are often
assessed using standardized, norm-referenced measures to determine the extent and
nature of the delay and to provide guidelines for early intervention programs that
will target skills that require remediation. Repeated assessments are essential to chart
progress and any “changes in the rate of development in order to arrive at a valid
diagnosis” (Sattler & Hoge, 2006, p. 440).
Intellectual developmental disability (formerly mental retardation) Currently,
IDD refers to significantly subnormal intellectual functioning in the presence of
impairment in adaptive functioning (life skills, such as communication, self-help,
leisure activities) that manifest during the developmental period. Cognitive deficits
are considered significant if an IQ (intelligence quotient) score on a standardized
measure of intelligence is two standard deviations (sd) below the norm (IQ of approximately 70, when the average IQ is 100). Standardized measures of adaptive functioning are often obtained through questionnaires completed by parents and teachers.
While developmental delays are likely to remit with appropriate intervention, children
who have IDD will experience life-long difficulties in areas requiring “higher order
cognitive processes (such as efficient problem-solving strategies, generalization and
abstraction)” compared to “subordinate processes (such as attention, rehearsal, ability
to inhibit responses, and discrimination of the elements of a problem)” (Sattler &
Hoge, 2006, p. 438).
Learning disability: general versus specific The general public can be confused
since the term “learning disability” has been used interchangeably to refer to IDD on
various websites, and in various publications, especially in the United Kingdom. The
Early Onset Problems: Preschool and Primary School
165
Royal College of Psychiatrists (2004, p. 1) has attempted to clarify the distinction
between a general learning disability and a specific learning disability, stating
that a child with a general disability “finds it more difficult to learn, understand and
do things compared to other children of the same age.” Therefore, while a general
learning disability (IDD) refers to reduced overall capacity to learn due to lowered
cognitive ability/intelligence quotient (an IQ of approximately 70 or below), the
term specific learning disability is used to refer to a learning difficulty in a specific area,
such as reading (dyslexia), writing, or understanding what is said to them, despite
having general learning ability at least within the average range (an IQ range of at
least 85–115). Specific learning disabilities will be addressed in Chapter 8.
A major communication gap
In North America, the term learning disability is synonymous with specific
learning disability, which refers to a significant discrepancy between intelligence
(usually average or above) and academic performance (well below average). Specific learning disabilities can occur in reading (dyslexia), writing, or mathematics.
However, in the United Kingdom, the term learning disability can also be used
as a generic term to refer to intellectual disability, a generalized impairment in
learning capacity and adaptive functioning due to subnormal intelligence.
The nature of IDD IDD is defined as a condition of subnormal intellectual functioning (DSM) or arrested/incomplete development of the mind (ICD) with accompanying impairments in adaptive functioning. IDD manifests within the developmental
period, prior to 18 years of age.
Intelligence (IQ) Historically, intellectual deficit has traditionally been classified by
degree of severity (mild, moderate, severe, or profound) based on IQ scores obtained
from individually administered intelligence tests. These tests have a mean (average) of
100 and a standard deviation (sd) of 15. Functioning levels of those diagnosed with
IDD can vary depending on the IQ scores. Those with mild impairment (IQ range 50
to 70) can be expected to achieve academic levels as high as the sixth grade, and be
gainfully employed with minimal supervision, while those with moderate levels (IQ
range 35 to 49) may achieve more modest education levels and work in sheltered
workshops. Those with severe (IQ range 20 to 24) and profound (IQ range below
20) levels of IDD will experience more pronounced impairments due to increased
neurological dysfunction. Approximately 85% of all those classified with IDD will
have a mild level of disability, while 10% will experience moderate levels of impairment
(APA, 2000).
The way in which intellectual disabilities are conceptualized has continued to evolve,
with the AAIDD shifting its emphasis from classifications based on IQ range to more
practical applications based on levels of service needed. This model is based on the
intensity of intervention required, ranging across intermittent, limited, extensive,
and pervasive service needs.
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68% of
population
Normal,
Bell-shaped Curve
.13%
4σ
2.14%
–3σ
13.59%
–2σ
34.13%
–1σ
34.13% 13.59%
0
+1σ
2.14%
+2σ
+3σ
130
145
.13%
+4σ
Standard deviations
55
70
85
100
115
Standard scores
Intelligence (IQ) scores:
Mean (average IQ) = 100
Standard deviation (SD) = 15
68% of population score within 1 SD of the mean (85 to 115)
2% of population score 2 SD below the mean (IQ 70)*
2% of population score 2 SD above the mean (IQ 130)**
* IQ 70 usual cut-off for mental retardation
**IQ 130 usual start point for giftedness
Figure 7.1 Standard normal distribution and IQ scores.
The measurement of intelligence Recall that the normal distribution was previously
discussed when the T score distribution was introduced (Figure 5.1). The relationship
of IQ scores (standard scores) to the normal distribution is presented in Figure 7.1.
The majority of individuals (68%) will score within 1 sd of the mean (IQ range
85–115). Note that as scores move away from the center, the population under the
curve shrinks on either side of the midpoint. An IQ score of 70 is 2 sd below the
mean and is the cut point for a diagnosis of IDD. Approximately 2% of the population
can be expected to obtain an IQ score below 70. On the other hand, individuals who
obtain an IQ score of 130 (2 sd above the mean) are functioning at the ninety-eighth
percentile, which is often seen as the cut point for “gifted” classifications which include
the top 2% of the population.
With the introduction of mandatory education, the French government commissioned Alfred Binet (1857–1911) and Théodore Simon (1873–1961) to develop a
measure of mental ability to identify children at risk for academic difficulties. The
original Binet–Simon Scales (1905) consisted of 30 questions of increasing difficulty
based on age-related cognitive probes (Sattler, 2001). In 1916, Terman devised the
intelligence quotient (IQ) to provide a ratio IQ of a child’s mental age (MA) relative to chronological age (CA). Although the ratio IQ has since been replaced by the
deviation IQ derived from more sophisticated statistical procedures, the ratio IQ can
be a helpful heuristic in understanding the relationship between mental age (MA) and
chronological age (CA), as is evident in the following example: Robby is five years
old (CA), but has the mental age of a three-year-old (MA). His ratio IQ would be 60
which would likely place him in the mild range of mental retardation.
Early Onset Problems: Preschool and Primary School
167
Ratio IQ:
IQ =
MA
× 100
CA
Example (Robby):
IQ =
3
× 100 = 60
5
Adaptive functioning Impairment in adaptive functioning (ability to function
independently) is a criterion for IDD. Deficits are measured using standardized scales
of social maturity and adaptation, which will be discussed shortly. Neither the DSM
nor the ICD provides guidelines regarding the extent of “deficit” required in adaptive
functioning to meet the criteria for IDD; however, the DSM does indicate that deficits
must exist in at least two of these 10 adaptive areas: communication skills, self-care, home
living, social/interpersonal skills, use of community resources, self-direction, functional
academic skills, work, leisure, or health and safety.
Developmental and associated features The majority of children with IDD have mild
deficits and will benefit from special education resources available in their own communities, although those with greater needs may require more comprehensive services.
Early identification is essential, since brain development is rapid in the first two years
of life. Delays or deficits may be evident in the following global areas:
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gross motor skills (sitting, walking);
fine motor skills (drawing, letters, coloring)
communication skills (speech, articulation, vocabulary);
cognitive skills (problems solving, transferring information from one situation to
another);
social skills.
Behavior problems can add to academic or social difficulties and those with comorbid communication problems, self-injurious behaviors, stereotypical movements, and
overactivity are at increased risk for negative outcomes (Aman, Hammer, & Rohahn,
1993).
Comorbidity Children with IDD are four times more likely to have comorbid
disorders than peers without IDD (APA, 2000).
IDD and comorbidity
The most common disorders associated with IDD include: ADHD, mood disorders, PDD, and stereotypical movement disorder (APA, 2000). Specific types
of IDD may exhibit certain patterns of comorbidity.
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Subtypes and prevalence: etiology of chromosomal abnormalities/genetic origins
Down syndrome Children with Down syndrome (DS) are born with a defect on
chromosome 21; either an extra number 21 chromosome (trisomy 21) or damage
to the chromosome. Children with DS have unique physical characteristics (short
stature, almond-shaped eyes, short broad hands, low muscle tone) and may experience
problems with motor skills (awkwardness, lack of coordination) and speech (grammar,
expressive language, and articulation). They have strong imitative skills. The average
IQ range is between 30 and 70, with the average IQ score around 50 (Chapman &
Hesketh, 2000; Vicari, 2006). IQ scores tend to decrease with age (Pennington,
Moon, Edgin, Stedron, & Nadel, 2003). Those with upper level Down syndrome
(IQ in the lower average range: 80–90) do not meet criteria for a diagnosis of IDD.
DS and child-bearing age
The prevalence rate for DS is usually one in 800 births; however, for women
over 45 years of age, the risk increases to one in 25 births.
Prader–Willi syndrome Individuals with Prader–Willi syndrome have a defect
on chromosome 15, inherited from the father, causing mild intellectual impairment
(IQ range 60–80) (Milner et al., 2005). Low muscle tone and weak reflex responses
are evident at birth. School-age children have short stature (small hands and feet),
poor emotion regulation (impulsivity, temper tantrums, mood swings), compulsive
eating, aggression, and stubbornness (Dykens & Cassidy, 1995). Obsessive compulsive
behaviors and picking at their skin can be problematic (Wigren & Hansen, 2005).
Compulsive eating can result in obesity.
Angelman syndrome A defect on chromosome 15, inherited from the mother,
results in Angelman syndrome, once called “happy puppet” syndrome, due to frequent and inappropriate laughing/smiling that accompanies the disorder (Horsler &
Oliver, 2006). Developmental delay, speech impairment, and movement disorder are
associated characteristics. The syndrome is rare (one in 10,000 births), and microcephaly (small head size), seizures, and a flat-shaped head may be evident (Horsler &
Oliver, 2006).
Williams syndrome (WS) J.C.P. Williams, a New Zealand cardiologist, identified
Williams syndrome (WS) in a number of cardiovascular patients. Although caused
by a random mutation on chromosome 7 (ELN, a gene responsible for maintaining
heart valves and blood tissue, is missing), recipients have a 50% risk of passing on the
mutation to offspring. Children with WS are hypersensitive to sound and have distinct
facial features including puffiness around the eyes, a wide mouth, and a short nose.
Infants can be colicky and irritable, while adolescents are prone to diabetes (Bellugi
et al., 2007).
Individuals with WS have well-developed verbal skills (verbal IQ) and poorly developed visual-spatial skills (performance IQ). Rourke et al. (2002) found individuals
Early Onset Problems: Preschool and Primary School
169
with WS share many processing deficits with children who have nonverbal learning
disabilities (NLD) evident in right hemisphere dysfunction.
“Hypersociability, including overfriendliness and heightened approachability
towards others, combined with anxiety relating to new situations and objects and
a difficulty forming and maintaining friendships with peers” can be evident (Bellugi
et al., 2007, p. 99). Bellugi et al. (2007) found an intense preoccupation with faces
even in toddlers with WS, who were more interested in gazing at and interacting with
researchers than engaging with toys. Hypersensitivity to sound and enhanced musical
ability have also been found in individuals with WS.
Fragile X syndrome Mild to moderate levels of IDD are associated with Fragile X
syndrome resulting from a defect in the Fragile X MR1 (FMR1) gene which produces
a protein necessary for normal brain development. Children may demonstrate challenging behaviors (aggression in males, withdrawal in females), based on the degree
of damage to the gene (Hall, De Bernardis, & Reiss, 2006).
Phenylketonuria (PKU) PKU is caused by two recessive genes that carry inborn
errors of metabolism (IEM). Infants lack the enzyme required for amino acid conversion necessary to produce phenylalanine which is essential for body functioning.
If not detected within the first year of life, irreversible damage can result. Routine
screening for PKU at birth is conducted globally (e.g., in the United States, Canada,
the United Kingdom). In the United Kingdom, annually 60–70 infants (of 793,000
births) test positive for PKU (Thomason et al., 1998). Early detection and placement
on a low phenylalanine diet can reverse the effects and return intelligence to normal.
Subtypes and prevalence: etiology of environmental origins Environmental toxins (teratogens) can cross the placenta and compromise the embryo, especially between
three and eight weeks’ gestation, when the nervous system and vital organs undergo
significant development.
Substance use/abuse Drugs (such as cocaine, crack) can increase risks for physical
defects, brain dysfunction (hemorrhages and seizures), low birth weight, and damage to the central nervous system (Espy, Kaufmann, & Glisky, 1999; Richardson,
Hamel, & Goldschmidt, 1996). Fetal alcohol syndrome (FAS) or fetal alcohol
effects (FAE, a milder form of FAS) can be the end result of maternal alcohol consumption during pregnancy. Approximately 33% of infants born to mothers who
consume excessive alcohol will develop FAS (Streissguth, Bookstein, & Barr 2004).
Facial features include an underdeveloped upper lip, widely spaced eyes, and a small
head, which will be less pronounced over time. However, cognitive deficits, hyperactivity, and impaired motor coordination often persist (Schonfeld, Mattson, & Lang,
2001).
Lead-based paint Children can be exposed to lead-based paint by eating paint
chips or living in residences where peeling paint releases toxins. Prenatal exposure can
result in brain damage and other side effects (Davis, Change, Burns, Robinson, &
Dossett, 2004). Higher lead levels are associated with increased need for special
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education resources and problems in attention, memory, learning, and behavior
(Coppens, Hunter, & Bain, 1990; Davis et al., 2004).
Rubella If a mother is exposed to rubella during the embryonic period (three to
eight weeks’ gestation), there is a 50% risk that the embryo will develop congenital
rubella syndrome which can result in multiple handicaps, including: sensory deficits
(hearing, vision), reduced mental capacity, aggressive tendencies, and/or self-injurious
behaviors (Carvill & Marston, 2002; Eberhart-Phillips, Frederick, & Baron, 1993).
Birth trauma Problems encountered during birth or delivery can result in anoxia
(oxygen deprivation), which can cause deficits in intellectual functioning.
Health and injuries Reduced mental capacity can result from contracting
encephalitis or meningitis, poor prenatal care, severe malnutrition, or acquired brain
injuries through accidents.
Assessment Evaluation and identification of IDD will often involve a mental health
team composed of a number of professionals. A full developmental, familial, and
medical history can provide information about the etiology, severity, and specific
nature of IDD and any comorbid features. Goals of the assessment will be to determine
areas of weakness in order to establish intervention strategies, and to identify the child’s
strengths which can increase the success of the intervention program.
An individually administered intelligence test will determine the level of the child’s
cognitive functioning, pattern of strengths and weaknesses, and whether the child
meets the criteria for diagnosis. Several intellectual assessment instruments are available
depending on the child’s age, and any cultural or second language considerations.
Some of the most common assessments are presented in Table 7.1.
While some of the measures incorporate language-based components, a number
of instruments are available for assessment of individuals who would be penalized
if language were a requirement. These instruments are either language-free (Leiter
International Performance Scale; Raven’s Progressive Matrices) or contain a nonverbal
ability scale (Differential Abilities Test). In addition to the assessment of cognitive
functioning, assessments of adaptive functioning would also be administered. Some
common adaptive instruments are also listed in Table 7.1.
Early intervention and prevention
Early intervention (EI) In the formative years, the brain is highly plastic and has
the potential for rapid development (Kolb, Brown, Witt-Lajeunesse, & Gibb, 2001).
Early intervention programs (in the first five years) can act to halt further cognitive
declines (Guralnick, 1998), and improve future school success (Stattin & KlackenbergLarsson, 1993). Roberts, Mazzucchelli, Studman, and Sanders (2006) found parents
who participated in a behavioral family intervention program (Stepping Stones Triple
P) reported a reduction in stress and improvements in both maternal and paternal parenting style, while preschoolers demonstrated fewer behavior problems than controls.
School- and home-based programs In the United States, numerous federally funded
Head Start Programs were launched in the 1960s with various degrees of success.
One of the most successful programs was the High/Scope Perry Preschool Project
Early Onset Problems: Preschool and Primary School
Table 7.1
171
Common assessment instruments for neurodevelopmental disorders
Instrument
Individual intellectual assessments
Bayley Scales of Infant and
Toddler Development-III
(Bayley, 2005)*
Wechsler Preschool & Primary
Intelligence Test (WPPSI-III)
(Wechsler, 2002a)*
Wechsler Intelligence Scale for
Children (WISC-IV) (Wechsler,
2002b)*
Stanford Binet, 5th Edition
(Roid, 2003)
Differential Ability Scales, 2nd
Edition (DAS II) (Elliott, 2007)
Leiter International Performance
Scales-Revised (Roid, Gale, &
Miller, 1997)
Raven’s Standard Progressive
Matrices (SPM/MHV) (Raven,
Raven, & Court, 2004)*;
Raven’s Colored Progressive
Matrices (CPM/CVS) (Raven,
2003)*
Adaptive behavior scales
Vineland Adaptive Behavior
Scales, Second Edition
(Vineland-II) (Balla, Cicchetti,
& Sparrow, 2005)
Adaptive Behavior Assessment
System (ABAS II) (Harrison &
Oakland, 2003)
Autism spectrum
Autism Spectrum Rating Scales
(ASRS) (Goldstein & Naglieri,
2010)
Autism Diagnostic Interview,
Revised (ADI-R) (Rutter,
LeCouteur, & Lord, 2003)
Childhood Autism Rating Scale –
2nd Edition (CARS 2)
(Schopler, Van Bourgondien,
Wellman, & Love, 2010)
Note: *UK norms available.
Age levels
Assesses
1–42 months
Five developmental domains:
cognition, language,
social-emotional, motor, and
adaptive behavior
Full scale IQ, verbal IQ,
performance IQ
2 years
6 months–
7 years
3 months
6–16 years
2–85 years
2 years
6 months–
17 years
11 months
2–20 years
Verbal comprehension, perceptual
reasoning, processing speed,
working memory index scores and
full scale IQ
Full scale IQ, verbal IQ,
performance IQ
Verbal ability, non-verbal ability,
spatial ability, general cognitive
ability (GCA)
Reasoning, visualization, attention,
and memory (language-free)
SPM: 7–18
years
CPM: 4–11
years
Progressive matrices are either
Standard (SPM) or Colored
(CPM) and accompanied by Mill
Hill Vocabulary (MHV) or
Crichton Vocabulary Scale (CVS)
Birth–18 years
11 months
Development in four domains:
communication, daily living,
socialization, and motor skills
Birth–21 years
Assesses 10 adaptive skills (DSM)
plus three general areas (American
Association of Mental
Retardation)
2–5 years;
6–18 years
Socialization, social/emotional
reciprocity, atypical language,
stereotypical/rigid behaviors
Diagnosis/differential diagnosis and
treatment planning; language,
social reciprocity, atypical
behaviors
Parent and teacher ratings of autistic
behaviors for low- to
high-functioning autism
2 years +
2 years +
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which followed 123 high-risk African American children living in poverty between
1962 and 1967 (58 were assigned to the program; 65 served as controls with no
intervention). The average IQ for all children was between 70 and 85. Children
attended the preschool for 2.5 hours per day, five days a week, over the course of two
years. The preschool teachers made weekly home visits of 1.5 hours.
High/Scope Perry Preschool Project
Academically, 15% of children in the program required special education compared to 34% of controls, and 71% graduated from high school compared to 54%
of controls. By 27 years of age, those in the control group had twice the number
of arrests, while social assistance was required by 32% of the controls, compared
to 15% of the program group (Schweinhart, Barnes, & Weikart, 1993). A costbenefit analysis revealed that the public benefitted at a rate of $7.16 for each
dollar invested in the program (Barnett, 1993).
During 2003–2004, the European Agency for Development in Special Needs Education (EADSNE, 2005) compiled a summary report on early childhood intervention
(ECI) based on information provided by 19 countries. The report discussed the
applicability of the ecologic-systemic model (Porter, 2002) to ECI programs in the
United States and Europe. The model draws on several perspectives already discussed
(attachment, social learning theory, and transactional/ecological) and focuses on child
development as:
r
r
r
r
holistic (competencies in all areas);
dynamic (interactive and responsive to changing developmental needs);
transactional (changes are reciprocal and on-going);
singular (individual differences result in individual perspectives).
How many children need and receive special education
services?
In the United States, six million children (aged three to 21 years) receive special
education services (Wilmshurst & Brue, 2005). In the United Kingdom, an
estimated 1.7 million pupils in schools have special educational needs, while
250,000 have Statements of special educational need, the majority of whom are
disabled (Department of Health, 2002).
Prevention programs There are several levels of prevention programs available to
reduce potential risk factors, namely: primary, secondary, and tertiary prevention.
Early Onset Problems: Preschool and Primary School
173
Primary prevention Dissemination of information concerning appropriate nutrition
in pregnancy to prevent low birth weight babies is an example of primary prevention.
Programs are normally universal (i.e., targeting all women of child-bearing age).
Secondary prevention programs Secondary prevention programs focus on highrisk populations and offer selective prevention targeting specific needs; for example,
training parents to promote social engagement for inhibited children.
Tertiary prevention programs Tertiary prevention programs provide indicated
prevention specific to the area of need (e.g., parent behavioral management programs
for problem behaviors) and target a population who already exhibit problems with the
goal of reducing or preventing the problems from getting any worse.
Autism spectrum disorders (pervasive developmental disorders)
The category of pervasive developmental disorders (PDD) in the ICD and DSM
has traditionally housed five disorders (autism, Asperger disorder (AD), childhood
disintegrative disorder or other disintegrative disorder, Rett syndrome, and pervasive
developmental disorder not otherwise specified (PDDNOS)). The disorders share features of qualitative impairments in communication, social reciprocity, and range of
interests/activities (stereotypical patterns of behavior). The ICD and DSM criteria
have met with criticism for failure to distinguish effectively between AD and autism
(Woodbury-Smith, Klin, & Volkmar, 2005), and growing discontent with increased
numbers of children diagnosed with PDDNOS based on limited criteria (Scheeringa,
2001). Currently, criteria for AD require ruling out communication delay or impairment; however, researchers have found children who meet criteria for AD but who
have language problems (Eisenmajer et al., 1998), while others have found children
with autism who do not demonstrate language delay (Miller & Ozonoff, 2000). Furthermore, some feel that communication problems in social pragmatics in those with
AD are not adequately recognized by the current criteria (Klin, Volkmar, Sparrow,
Cicchetti, & Rourke, 1995; Woodbury-Smith et al., 2005).
As a result, current revision plans for the ICD and DSM include potentially conceptualizing autism, AD, and PDDNOS and child disintegrative disorder as the autism
spectrum disorders based on “significant and early-arising difficulties in basic aspects
of social-communication and restricted, repetitive behaviors or interests” which are
“the commonalities that strongly define this group” (Lord & Bishop, 2010, p. 4).
With this in mind, the two defining criteria would include: social/communicative
deficits and fixated/repetitive behaviors. Conceptually, social communicative behaviors would represent one cluster of symptoms instead of two.
ASD: nature and course Deficits in social communication and social interaction are
evident in the following three areas:
r
deficits in reciprocal social-emotional responses; children with ASD often do not
initiate or engage in social conversation, share interests, or participate in social
referencing;
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Clinical and Educational Child Psychology
deficits in nonverbal communication such as eye contact, social gestures, body
language, facial expressions, and poor integration of verbal and nonverbal communication;
lack of interest in or development of age-appropriate relationships with others
(excluding the caregiver); lack of sharing, imaginative play, or imitation.
Restricted range of activities and engagement in repetitive patterns of behavior are
evident in two of the following areas:
r
r
r
r
repetition of behavior, such as repetitive speech, motor movements (hand flapping,
rocking), or perseverance with objects (lining up objects or playing with parts of
objects, such as spinning the wheel of a car);
rigid adherence to routines, repetitive need for sameness (food, routines), and
extreme resistance to change;
restricted range of interests and intense preoccupation with themes (such as numbers, maps, and so on) or attachment to objects;
hyper- or hypo-reactivity to environmental stimuli of a sensory nature (such as
lights, sounds, textures, smells); possible adverse reactions to certain sensory input.
Developmental features Children with ASD lack social interaction skills such as
social referencing, or sharing interests with others (joint attention behavior). Communication may be minimal, or marked with oddities such as pronoun reversals,
echolalia (repeating rather than responding), and robotic in nature. Social play is
limited or non-existent. There is often a preoccupation with nonfunctional routines
(lining things up), or other forms of self-stimulation that increase isolation from
others. There can be an insistence on sameness (IS) (rigidity of routines, inflexibility to environmental changes, compulsions/rituals) that adds to child management
issues, or repetitive sensory and motor behaviors (RSMB) (unusual sensory interests, self-stimulation, rocking, and repetitive acts) that tend to disengage children from
the outside world. Szatmari et al. (2006) found that children who engaged in more
RSMB behaviors were more delayed, while those with the IS factor demonstrated
higher intellectual functioning.
Intellectual functioning It was initially thought that 70% of individuals with autism
have comorbid IDD, with 30% in the mild to moderate range, and 40% in the severe
to profound range (Fombonne, 2003). However, more recent reports suggest that
IDD may occur in only 50% of cases (CDC, 2000).
Autism and IQ: a biased report?
Concerns have been raised that reports of IQ deficits may be overestimated. IQ
test scores may be inaccurate due to lack of motivation and deficits in language
skills in individuals with autism (Edelson, 2006; Freeman & Van Dyke, 2006).
Early Onset Problems: Preschool and Primary School
175
The term high functioning autism (HFA) has been used to refer to individuals
with autism with an IQ score of above 70 (Klin, Volkmar, & Sparrow, 2000). Males
are nine times more likely to have HFA compared to females (Volkmar, Szatmari, &
Sparrow, 1993), and are four times more likely than females to be diagnosed with
autism (CDC, 2000).
Asperger disorder (AD) The category of AD has been controversial. While some
suggest that AD represents a less severe form of autism on the spectrum, others
support retaining the separateness between these two disorders, since children with
AD present with “fewer symptoms and have a different presentation” (Volkmar et al.,
1994, p. 1365). For example, while those with more severe autism perseverate on
parts of objects (such as spinning a wheel), the child with AD perseverates on themes
or topics of interest (such as dinosaurs or cars) and can become quite knowledgeable
in these “savant skills” (Klin & Volkmar, 1997). Some children with AD may be
preoccupied with numbers or letters and some can be hyperlexic, decoding words at
a very early age. Although able to form attachments to family members, these skills
do not transfer to peers. A pedantic monologue often replaces two-way conversations.
Deficits in understanding social pragmatics can be painfully obvious when they attempt
to join peer groups in adolescence (Klin & Volkmar, 1997). Their awkward gait and
lack of coordination also may set them apart from their peers.
Rourke et al. (2002) found shared traits in those with AD and nonverbal learning
disabilities (NLD): verbal strengths (left hemisphere) and deficits in right hemisphere
processing (weaknesses in social interaction, complex reasoning, and nonverbal communication).
Woodbury-Smith et al. (2005) suggest conceptualizing autism and AD as two
different types of social disability with their own unique patterns of behaviors and
communication deficits. This would reinforce the need to recognize that communication abnormalities do exist in those with AD (in the form of pragmatic communication impairments) that “interfere with the ability to initiate and sustain a
conversation,” even though deficits are “fundamentally different from the type of
language and communication impairments described in autism in which the language
is delayed, echolalic, idiosyncratic and repetitive” (Woodbury-Smith et al., 2005,
p. 238).
Theory of mind
Daria loves chocolate. When Daria leaves the room, Molly watches her teacher
replace the chocolate in her lunch box with crackers. The teacher asks Molly:
“When Daria returns to the room, what will she think is in the lunch box?
Theory of mind Researchers have studied theory of mind problems, such as in the
example in the box, and found varied success rates for those with autism, HFA, and
AD. Successfully solving the dilemma requires awareness that others have a “mental
set,” or belief system based on their own perceptions. When faced with the dilemma,
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children with AD continually perform better than those with autism or HFA (Ozonoff,
Rogers, & Pennington, 1991).
ASD: prevalence rates and etiology Four to five times more males are diagnosed with
autism and AD; however, females diagnosed with autism tend to be more severely
affected (APA, 2000). Prevalence rates for autism are four times that of AD (Fombonne, 2003).
Autism: a growing concern
Prevalence rates for autism initially ranged from five to 25 cases per 10,000
(APA, 2000). However, rates have escalated, globally. In California, rates
jumped from 44/100,000 in 1980 to 208/100,000 in 1994 (Dales, Hammer,
& Smith, 2001). In the United Kingdom, cumulative incidence ratings rose
from 7/10,000 in 1988, to 28/10,000 in 1993, and 33/10,000 in 1996 (Jick
& Kaye, 2003).
The most recent reports from the Centers for Disease Control and Prevention
(CDC, 2000) suggest that the prevalence rate for ASD in the United States is 1/70
for boys and 1/315 for girls, with an overall rate of 1/110 (CDC, 2009). These
rates are very similar to those reported by Baird et al. (2006) concerning children
in south-west London (United Kingdom), suggesting proportions of global concern.
Recent reviews suggest that PDDNOS is now the most highly diagnosed category of
ASD, with twice as many cases reported compared to autism (Fombonne, 2009).
Given the dramatic increase in rates for autism, some have questioned whether
a childhood vaccine (particularly the MMR vaccine against measles, mumps, and
rubella), or a preservative (thiomersal), in vaccines might be implicated. However,
evidence is not supportive, and Jick and Kaye (2003) suggest increases are likely due
to improved practices for identification of the disorder. Coincidentally, the MMR
vaccine is typically administered around the time that symptoms of autism become
more evident (12 to 15 months; and three to five years).
Etiology: genetics, brain structure, and function There is an increased risk for
autism linked to increased age of the parent (mothers and fathers) at the time of
conception (Grether, Anderson, Croen, Smith, & Windham, 2009). If one sibling
has autism, there is a 3–6% risk to the other siblings (Nicholson & Szatmari, 2003).
About 25% of those with autism have elevated levels of serotonin (Klinger & Dawson,
1996). Increased head circumference has been reported, albeit the corpus callosum (lateralization of function) is reduced. In social cognitive situations, there is
limited activity of the amygdale (processing emotion), while parts of the brain are
activated that are most often associated with processing objects, rather than people (Pierce, Muller, Ambrose, Allen, & Courchesne, 2001). Recent investigations
of adults with ASD have found atypical amygdale responses with poor connectivity to associated neural pathways (Gaigg & Bowler, 2007), and reduced receptors
in the serotonergic (5-HT) system responsible for “modulating social behaviour,
Early Onset Problems: Preschool and Primary School
177
amygdale response to facial emotion and repetitive behaviours” (Murphy et al.,
2006, p. 934).
In a recent study conducted in London, Ecker et al. (2010) analyzed brain scans
(obtained through functional magnetic resonance imaging) of 20 adults with ASD
using a pattern classification technique previously used in facial recognition studies.
Compared to controls and adults with ADHD, Ecker et al. (2010) were able to
predict, with 90% accuracy, the scans belonging to the group with ASD due to a
consistent pattern of increased thickness of tissue in grey matter located in areas of
the frontal and parietal lobes that are associated with specific behaviors and language.
If the study is replicated with children, it may provide a “biomarker” for ASD which
has been elusive to date.
ASD: assessment The assessment and diagnosis of ASD is currently based on matching
descriptions and observations to criteria as set out in the DSM or ICD. However, as
Lord and Bishop (2010) point out, currently there are few “developmental referents”
to guide professionals in defining symptoms for different ages and skill levels for this
complex and diverse disorder. In addition, although a number of instruments and
rating scales are available, some of which are presented in Table 7.1, there is no
prescribed protocol for assessment. However, based on best practices, the National
Autism Center (2009) suggests that assessment of autism should include:
r
r
r
r
detailed developmental history;
evaluation of the child’s developmental cognitive, adaptive, and behavioral functioning;
direct observation of the child’s play, language, and social interaction;
a physical examination.
Among the instruments that have been used to identify ASD, the Autism Diagnostic Observation Schedule (ADOS; Lord et al., 1989) is an instrument that
has stood the test of time, with a recent replication of results confirming initial rates for prediction and validity (Gothman et al., 2008). The instrument
has been available commercially since 2001 through Western Psychological Services (WPS). ADOS is accepted as the “gold standard of autism diagnosis . . .
based on a combination of results gleaned from a diagnostic interview and clinical judgment of an autism expert”; this developmental play-based assessment protocol “involves the systematic observation of key features associated with ASD”
(Wilczynski et al., 2011, pp. 569–570). The instrument takes about 45 minutes
to complete and requires fairly extensive training to administer. Another play-based
assessment, also requiring trained practitioners, is the Screening Tool for Autism
(STAT; Stone, Coonrod, & Ousley, 2000). The Modified Checklist for Autism in
Toddlers (M-CHAT; Robins, Fien, Barton, & Green, 2001) is a screening device
for ADS developed primarily for pediatricians to obtain parent ratings at their
24-month visit.
ASD: treatment and intervention The need for early identification and intensive
intervention has been well supported by research (Dawson et al., 2009; Lovaas,
1987). In addition to pharmacological treatment that may accompany interventions
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for ASD, the National Autism Center (2009) conducted a comprehensive review of
empirically based intervention practices and comprehensive treatment models. The
report suggests a number of intervention practices, including behavioral methods,
such as conducting a functional behavioral analysis to link interventions to target
behaviors, modeling, peer training, self-management strategies, and the use of storybased interventions. Given the diversity of ASD, it is important that behavioral packages be developed to address a student’s individual needs and to incorporate family
into the process (Lord & Bishop, 2010; National Autism Center, 2009; Wilczynski
et al., 2011).
Lovaas: the UCLA ABA Program Ivar Lovaas (1987) developed the UCLA treatment program for autism based on principles of applied behavioral analysis (ABA).
The program involved 40 hours of home and clinic intervention per week, over three
years (from two-and-a-half to five-and-a-half years of age). By seven years of age,
almost half (47%) of the children in this intense intervention increased their IQ by
37 points and were attending regular school programs.
The UCLA model was replicated in a community setting, using a quasi-experimental
design, since assignment to group was not random, but based on parents’ preference.
Results revealed that the experimental group (21 children) achieved significantly
higher IQ and adaptive scores relative to controls (21 children) receiving regular
special education assistance (Cohen, Amerine-Dickens, & Smith, 2006).
The Schopler Program: TEACCH TEACCH (treatment and education for autistic and related communication handicapped children) originated from Duke University, in North Carolina (Schopler, 1994). The program targets communication
problems to reduce behavioral problems resulting from frustration, by developing
skills in intentional communication. The theory is that children will become motivated to communicate based on internal drives and needs (e.g., the child will be
motivated to learn the word water, if he or she is thirsty). Empirically, the TEACCH
program has been successful in reducing self-injurious behaviors (Norgate, 1998),
and more effective than non-specific educational alternatives (Panerai, Ferrante, &
Zingale, 2002).
The Early Start Denver Model: ESDM The ESDM model (Dawson et al., 2009)
was a rigorously designed manualized program using ABA methods for children with
ASD under 30 months of age who were randomly assigned to the ESDM or a community treatment control. The ESDM involved an intensive 15 hours of home-based
intervention focusing on interpersonal skills and verbal and nonverbal communication.
Parents were trained in behavioral strategies (positive reinforcement, use of positive
affect) and were instructed to use these skills for at least five hours per week (although
the average use was 16.3 hours per week). Program participants increased their IQ by
17 points compared to controls who demonstrated a seven-point increase in IQ.
Childhood disintegrative disorder (CDD) There is limited information about CDD,
a very rare condition afflicting approximately 2/100,000 males (Fombonne, 2009).
The onset of the condition occurs between two and 10 years of age, following at
Early Onset Problems: Preschool and Primary School
179
least two years of normal functioning. CDD is often accompanied by severe IDD and
possibly metachromatic leukodystrophy (MLD).
Metachromatic leukodystrophy (MLD)
The myelin sheath, a fatty covering that acts as an insulator around the nerve
fibers, increases the efficiency of neurotransmitter message transmission. MLD is
a lipid storage disease that impairs the development of myelin and is responsible
for a toxic build-up of lipids in the nervous system, liver, and kidneys and is
possibly responsible for loss of bladder function.
Children with CDD experience a progressive loss of function in several areas that
can include: language, social/adaptive skills, bowel or bladder function, and play
or motor skills. Atypical functioning in areas common to other ASD is also evident
(social communication, and a restricted range of activities/repetitive and stereotypical
patterns of behavior).
Etiology and treatment Little is known about the cause of CDD; however, a higher
incidence of epilepsy is reported relative to those with autism (Kurita, Koyama, Setoya,
Shimizu, & Osada, 2004). A phase of markedly fearful, anxious behavior can accompany the regressive period which includes loss of motor coordination, loss of physical
skills (dressing, toileting, self-feeding, and the development of ataxia or drooling)
and other neurological symptoms (Rogers, 2004). Treatments include medications to
control seizures and behavioral programs similar to those used for children with ASD.
Children with speech, language, and communication problems
Speech and language impairments: nature of disorders Children who have a language impairment (LI) perform below age expectations in language, including: the
acquisition of spoken language (expression, production, and comprehension) and
written language, and language usage (vocabulary, grammar, and pragmatics). Language difficulties may shift based on the child’s age and it may be difficult to determine
whether a child is experiencing late language emergence (LLE), a specific language
impairment (SLI), or selective mutism. Although it is suggested that LI can exist
comorbid with other disorders (such as ASD, LD, and selective mutism), LLE and SLI
are considered to be mutually exclusive. However, it is possible for a child to begin
with a diagnosis of LI and be later diagnosed with SLI. Language impairment can
cause a functional limitation in areas of communication, social engagement, academic
achievement, and career.
Late language emergence (LLE) For children who demonstrate LLE, delay in language onset will be determined prior to four or five years of age by comparing rates
of acquisition to expected language milestones (e.g., vocabulary, word combinations,
ability to follow directions, use of gestures, and so on). Children with LLE are at risk
for other developmental disorders, such as ASD, IDD, SLI, social communication
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disorder, or specific learning disabilities. Although the majority of children with LLE
are not reclassified as having SLI, at least one study found that 20% of children identified as having LLE at 24 months continued to perform below the norm on language
ability tests at seven years of age, compared to only 11% of controls (Rice, Taylor, &
Zubrick, 2008). Risk factors for LLE include being male (males have three times the
risk of females), having low birth weight (twice the risk), and having a family history
of late onset speech (Zubrick, Taylor, Rice, & Slegers, 2007).
Specific language impairment (SLI) In keeping with classical definitions of specific
learning disabilities (which will be addressed in the next chapter), determining the
existence of SLI entails a two-step process:
1. indication of below normal functioning on a standardized assessment of language
functioning, usually 1 sd below average (Tomblin, Records, & Zhang, 1996);
2. a determination that the SLI is not due to other impairments, such as lack of
opportunity to learn language, hearing deficits, or other pervasive disorders (such
as IDD or ASD).
However, whether nonverbal scores should be at least in the average range or expanded
to include nonverbal scores in the 70–85 range is an area of debate (Francis, Fletcher,
Shaywitz, Shaywitz, & Bourke, 1996). The controversy regarding the requirements for
nonverbal functioning have serious implications, conceptually and psychometrically,
since studies have shown lower prevalence rates for cases where nonverbal intelligence
is within the norm (Tomblin et al., 1997).
Specific language impairment (SLI) or auditory processing
disorder (APD)?
APD refers to “deficits in the neural processing of non speech sounds that do
not result from deficits in general attention, language or cognitive processes”
(Ferguson, Hall, Riley, & Moore, 2011, p. 211). Differential diagnoses of APD
and SLI have been problematic due to inconsistencies in definitions and lack of
consistency in diagnostic assessments for APD. Furthermore, children diagnosed
with SLI by speech and language pathologists and children diagnosed with APD
by ENT or audiology professionals often present with similar and overlapping
symptoms. In their recent comparative analysis of children diagnosed with SLI
or APD, Ferguson et al. (2011) found no difference between these two groups
on any of the audiological, language, or cognitive assessments conducted or any
of the parent questionnaires. The authors suggest that differential diagnosis was
based on “referral route” rather than any “actual differences.”
It can be difficult to reliably identify language impairments in very young children
(Dale, Price, Bishop, & Plomin, 2003). However, when SLIs are identified in the later
preschool years, they tend to be more persistent (Law, Boyle, Harris, Harkness, &
Nye, 2000; Tomblin, Zhang, Buckwalter, & O’Brien, 2003). In addition, children
Early Onset Problems: Preschool and Primary School
181
with SLI are at increased risk for longer-term negative outcomes academically (e.g.,
Catts, Fey, Tomblin, & Zhang, 2002; Young et al., 2002) and in psychosocial areas
(e.g., Tomblin, Zhang, Buckwalter, & Catts, 2000; Beitchman et al., 2001).
Social communication disorder (SCD) This category has been referred to by many
different designations, including “semantic pragmatic disorder” which has been used
primarily in the United Kingdom (Bishop & Rosenbloom, 1987), and refers to language problems resulting from difficulties with the semantics and pragmatics of social
communication. There has been significant debate as to whether the disorder is part
of ASD or a language disability in its own right. For example, Rapin and Allen (1998)
suggest that although the disorder can often occur in children with ASD, it can also
appear in children with other disorders such as hydrocephalus, Williams syndrome, and
other brain conditions. More recently there has been increasing support for considering social communication as a language disorder that is separate from other language
impairments involving syntactical qualities of speech, and that can also exist in populations without ASD (Bishop & Norbury, 2002; Tomblin, Zhang, Weiss, Catts, &
Ellis Weismer, 2004). Because deficits in social communication are part of the criteria
for ASD, the category of SCD would rule out those with ASD and would be reserved
for children with otherwise intact language skills, who experience specific deficits in
comprehension and communication in social situations based on poor ability to recognize and respond to subtle social nuances and understand non-literal interpretation
of conversational speech (e.g., the use of idioms).
Issues of fluency and voice In addition to impairments in language, some children also
experience problems of speech fluency, e.g., production of speech sounds (phonological errors of articulation, substitutions or omissions), stuttering, cluttering (rate,
clarity or organization of speech) or voice problems involving vocal pitch, loudness,
tone and quality. In a community-based study, Beitchman, Nair, Clegg, and Patel
(1986) estimated that 4.6% of five-year-olds with fluency issues had comorbid speech
and language disorders.
Although the consequences of having speech sound disorders may not be as
significant as for SLI, fluency problems can increase the risk for reading, and
other academic and social problems (Raitano, Pennington, Tunick, Boada, &
Shriberg, 2004). In clinical populations, high rates of comorbidity have been
reported among stuttering, speech sound disorders, and SLI (Blood, Ridenour,
Qualls, & Hammer, 2003). Onset of stuttering often occurs in the preschool years
and may remit spontaneously, although it can persist. Due to the embarrassment
often associated with stuttering, issues of self-confidence may result in restriction of
social and vocational activities (Kroll & Beitchman, 2005).
Prevalence rates and etiology
Prevalence rates Prevalence rates across studies vary widely. Epidemiological studies
suggest that between 13 and 19% of children will demonstrate LLE by 24 months
of age (Zubrick et al., 2007). Concerning SLI, Beitchman et al. (1986) found a
prevalence rate of 12.6% for five-year-olds, using a definition that did not require
normal nonverbal intelligence, while Tomblin et al. (1997) reported a prevalence
rate of 7.4% for SLI when other disabilities were excluded and nonverbal intelligence
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was required to be in the normal range. Among six- and seven-year-old children,
Law et al. (2000) found median prevalence estimates of 5.5% for the more exclusive
and 3.1% for the less rigorous definitions of SLI.
In order to clarify the nature of speech, language, and communication needs
(SLCN) of children living in the United Kingdom, the government commissioned
a report, the Bercow Report (Bercow, 2008), to review data collected in the United
Kingdom (Lindsay et al., 2008) with the goal of evaluating and improving services
to meet the needs of children with SLCN. Based on data generated for this report,
Lindsay et al. (2008) report that “a significant proportion of children in both primary
and secondary school with special educational needs have SLCN as their primary
need” (p. 14). Based on their data gathered in 2007, Lindsay et al. (2008) found that
approximately 50% of children in some socio-economically disadvantaged populations
have speech and language skills that are significantly lower than those of other children
of the same age. In addition, approximately 7% of five-year-olds (40,000) in England
had significant difficulties with speech and/or language, likely needing intervention at
some point, while approximately 1% of five-year-olds (5500) had the most severe and
complex speech, language, and communication needs (Desforges & Lindsay, 2010).
Prevalence rates for fluency disorders also vary by study. Studies of community
samples in North America have reported a rate of 15.6% for speech sound disorders in
three-year-olds (Campbell et al., 2003), and 3.8% for six-year-olds (Shriberg, Tomblin,
& McSweeny, 1999).
In an Australian study of over 10,000 children (kindergarten through grade six)
McKinnon, McLeod, and Reilly (2007) found a rate of 1.06% for speech sound disorders, and estimate 0.33% for stuttering, based on conservative procedures. Although
rates differ based on definitions and procedures used, studies are consistent in revealing
a reduction in prevalence rates with increased age (Shriberg, Kwiatkowski, & Gruber,
1994). Overall population rates for stuttering are less than 1%, ranging from a high
of approximately 1.4% for children two to 10 years of age to a low of roughly 0.37%
in adult populations (Bloodstein, 1995).
Etiology Genetic factors have been prominent in studies of the etiology of SLI,
and most SLIs can be linked to family history. Chromosome 6, 16, and 19 have
been implicated in SLI, while chromosome 6 has also been linked to dyslexia (Falcaro
et al., 2008; Rice, Smith, & Gayan, 2009). Children who have a first-degree biological
relative with a stutter are three times more likely to stutter than the norm (APA, 2000).
In their study of SLNC in children and adolescents in the United Kingdom, Lindsay
et al. (2008) suggest three areas most likely to be associated with SLCN: the existence
of a primary disorder in the area; cases where SLCN are secondary to another primary
factor such as a significant hearing impairment which impedes speech, language, and
communication; or lack of opportunity and exposure to adequate language models as
a result of social disadvantage.
Assessment and treatment Assessment and treatment of SLIs are primarily conducted
by speech therapists and speech pathologists trained in the evaluation and treatment of
deficits and delays in speech, language, and communication. Therapy can be provided
in individual or small group sessions. Elaboration of the specific instruments and therapeutic interventions available to speech therapists is beyond the scope of this book;
Early Onset Problems: Preschool and Primary School
183
however, Lindsay et al. (2008) suggest that, given the high prevalence rates for speech,
language, and communication problems among school children, a multi-tiered system of intervention/universal prevention should be implemented, similar to response
to intervention (RTI) procedures used in the United States (Reschly & Ysseldyke,
2002). The model would represent four tiers of service: language enrichment for all
children, as part of early development; language enrichment and targeted support
for half the population who experience language difficulties; targeting and specialist
support for those with significant primary impairments in speech, language, and communication (7%); and complex and long-term support from specialists, in addition
to targeted and universal applications for the most severe cases (Lindsay et al., 2008,
pp. 14–15).
Other early onset childhood disorders
Eating and feeding disorders of infancy and early childhood
Feeding disorder Feeding disorder is often characterized by “food refusal” or
restricted food intake with the possible outcome of failure to thrive (FTT). Forty
percent of young children evidence eating problems (Manikam & Perman, 2000),
although “picky” eaters often compensate by eating larger quantities of preferred
foods (Reau, Senturia, Lebailly, & Christoffell, 1996). However, children with FTT
represent 3–4% of children six years of age and younger who fail to meet weight expectations; demonstrate symptoms of irritability, withdrawal, and possible developmental
delays; and are responsible for between 1% and 5% of infant hospital admissions.
Although abuse and/or neglect were initially thought to be a causal factor, recent
research has shed doubt on this theory (Wright & Birks, 2000). Children with the
disorder evidence feeding disturbance by repeated avoidance of food or by restricting
intake. Sharp, Jaquess, Morton, and Herzinger (2010) found that behavioral interventions resulted in significant improvements in feeding behaviors, based on tracking
antecedent and consequent conditions as part of the regime for successful intervention.
Pica Children with pica repeatedly crave non-nutritive and non-food substances,
with younger children most likely to consume paint, cloth, plaster, and string, while
older children may eat sand, pebbles, leaves, and animal droppings. Adolescents may
eat clay or soil. Pica is often associated with IDD (which may include adult populations), and can be a symptom of ASD but also may exist in young children who
have normal intelligence. It is important to rule out cultural variations, since in some
cultures eating non-nutritive substances (clay) is sanctioned (APA, 2000).
Rumination disorder Rumination involves repeated regurgitation and re-chewing
of food. Later onset is often associated with mental retardation. Although the DSM
(APA, 2000) considers this a separate disorder, the ICD (WHO, 1996) considers
rumination as a possible symptom of feeding disorder, rather than a separate disorder.
If onset is between three and 12 months, rumination is most likely associated with
stressful conditions, or neglect. Weight loss can be severe, and even fatal in 25% of
cases.
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Selective mutism (SM) Children with selective mutism (DSM) or elective mutism
(ICD) are characterized by a failure to speak in specific social situations (school,
groups), while being able to speak in other situations (family, siblings, or close peers).
The mean age for SM is between 2.7 and 4.1 years (Bogels et al., 2010). There is a
quandary as to where SM should be clustered in classification systems, due to a poor
understanding of the etiology of the disorder, and as a result four different directions
have been suggested:
1. SM is a type of anxiety disorder, such as a variant of social phobia (SP) or social
anxiety disorder (SAD) (Bogels et al., 2010). This rationale is based on overlapping symptoms (anxiety and avoidance); the high rate of comorbidity between
these two disorders (65% of children with SM also meet criteria for SAD; Black &
Uhde, 1992; Kristensen, 2000); and the fact that fluoxetine which is successful in
the treatment of SAD (Kristensen, 2000) also is successful in improving symptoms
of SM (Bogels et al., 2010).
2. SM is an avoidant behavior pattern, similar to school refusal, which the child
acquires over time and is reinforced through refusal to speak which reduces anxiety
(Bogels et al., 2010).
3. SM is a strategy for emotion regulation by avoidance of speech, which serves to
lower the level of emotional arousal (Scott & Beidel, 2011). Parent reports of
the child’s shy temperament and Kagan’s (2001) research on inhibited children
provide support for this premise.
4. SM is part of the externalizing or oppositional disorders (Black & Uhde, 1992).
5. SM is a type of language disorder or impairment because 30–38% of children with
SM also exhibit speech and language disorders (Steinhausen & Juzi, 1996).
Assessment and treatment The majority of treatment investigations for SM have
been in the form of case studies, which, although providing rich information, reduces
the generalizability of results. However, success has been noted in studies using behavioral methods, such as shaping, systematic desensitization, and modeling (Pionek
Stone, Kratochwill, Sladezcek, & Serlin, 2002).
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8
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and Attention
Chapter preview and learning objectives
Specific learning disabilities: an overview
Definition of specific learning disabilities
SLD: nature and course
Issues in identification
The discrepancy criteria
Response to intervention (RTI)
Current conceptualizations
Specific types of learning disabilities
Specific reading disability (dyslexia)
Definition of reading disability
Nature and course
Prevalence and etiology
Assessment and treatment/intervention
Disorders of written expression (dysgraphia)
Definition of disorders of written expression
Nature and course
Prevalence and etiology
Assessment and intervention
Specific mathematics disability/mathematics learning disability
(MLD/dyscalculia)
Definition
Nature and course
Prevalence and etiology
Assessment and intervention/prevention
Nonverbal learning disabilities (NLD)
Definition
Nature and course
Prevalence and etiology
Assessment and treatment/intervention
Dyspraxia (developmental coordination disorder)
Definition
Nature and course
Clinical and Educational Child Psychology, First Edition. Linda Wilmshurst.
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Problems of Learning and Attention
Prevalence and etiology
Assessment and treatment
Problems of impulsivity, hyperactivity, and inattention
Attention deficit hyperactivity disorder (ADHD)
Definition
Nature and course
Prevalence and etiology
Assessment and treatment/intervention
References
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Chapter preview and learning objectives
In Chapter 7, readers were introduced to intellectual disabilities and pervasive developmental disorders (autism spectrum disorders) that pose life-long challenges to children
and adolescents. Readers were also acquainted with communication disorders and
impairments that influence speech and language, often accompanying other disorders
or representing a more specific area of impairment in their own right. In this chapter,
we look more closely at disorders that can have far-reaching implications, socially,
behaviorally, and emotionally, but whose main impact is evident in the specific challenges associated with unique types of learning difficulties. Children and adolescents
with specific learning disabilities (SLD) often have average intelligence and can have
above-average skills in some areas, relative to significant weaknesses in others. As
a result, children with learning disabilities are not a homogeneous group and can
present a complex mix of characteristics. Even within categories of disabilities, unique
patterns of strengths and weaknesses can be evident. Readers will gain an increased
understanding of the nature of the different types of learning disabilities; how they
influence learning at different developmental levels; as well as the causes, prevalence,
and interventions that can help children with SLD at home and at school.
Children with SLD often experience other comorbid disorders, such as attention
deficit hyperactivity disorder (ADHD), which will also be discussed at length in this
chapter. Although most individuals are familiar with the hyperactive-impulsive form
of the disorder, fewer realize that there are three variants of ADHD, and that some
children only have the inattentive type of ADHD. After reading this chapter, readers
will have an increased appreciation of the challenges facing individuals with ADHD.
Specific learning disabilities: an overview
The area of specific learning disabilities (SLD) has inspired debates concerning how
the disability is best defined and how children with SLD are best identified. Children
with a SLD have problems learning specific types of information, while their skills
remain intact in areas unrelated to their disability. For our purposes, after a general
discussion of the global nature and course of SLD, there will be a more detailed
discussion of five specific types of SLD: disorders of reading, disorders of written
expression, disorders of mathematics, nonverbal learning disabilities, and disabilities
related to motor skills (dyspraxia, or developmental coordination disorder).
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Definition of specific learning disabilities The following definition of a SLD is dictated
by federal special education law in the United States and has remained unchanged since
its inception in the mid-1970s. As such, a SLD is defined as:
a disorder in one or more of the basic psychological processes involved in understanding,
or in using language, spoken or written, that may manifest itself in the imperfect ability
to listen, think, speak, read, write, spell or do mathematical calculations, including conditions such as perceptual disabilities, brain injury, minimal brain dysfunction, dyslexia and
developmental aphasia. Specific learning disability does not include learning problems
that are primarily the result of visual, hearing or motor disabilities, of mental retardation,
of emotional disturbance, or of environmental, cultural or economic disadvantage.
(Federal Register, 2006, 300.8 (10), p. 46757)
SLD: nature and course
Hallahan and Mercer (2001) chronicle the history of specific learning disabilities
(SLD), from Kussmaul’s discovery of “word blindness” in an otherwise intact individual in 1897, to Hinshelwood’s publication on congenital word blindness in 1917
that ushered in an era of investigation and discussions surrounding the nature and
course of SLD. Because reading problems were found to exist, in spite of average ability, the importance of using intelligence as the benchmark for judging performance
relative to ability became an integral part of the definition of SLD. As a result, the
use of the discrepancy criterion became the main tool to identify the existence of
SLD (the difference between a student’s ability and expected achievement, relative
to actual achievement). The discrepancy criterion has been recognized by the DSM
(APA, 2000) and the ICD (WHO, 1993) as the definitive means of identifying children with SLD based on a significant discrepancy between achievement and IQ, with
achievement “substantially below” IQ, which “is usually defined as a discrepancy of
more than 2 standard deviations” (APA, 2000, p. 49). Exclusionary criteria require
that the disorder not be due to a sensory deficit, or go beyond what would be expected
given a sensory deficit. In the ICD-10 (WHO, 1993), specific developmental disorders of scholastic skills (SDDSS) recognizes learning problems in three academic areas
(reading, spelling, and arithmetic skills). As for the on-going revisions of the DSM-5
and ICD-11, it is uncertain whether the DSM will shift criteria to align better with the
Individuals with Disabilities Education Act (IDEA), and if so, how this might influence
revisions of ICD-11. The current status of the debate will be revisited shortly, when
the results of the Expert Panel White Paper (LDA, 2010) are addressed. But first, it
is important to review some of the initial concerns surrounding exclusive use of the
discrepancy criterion in the identification of students with SLD in the United States.
Issues in identification
The discrepancy criteria Growing discontent regarding the exclusive use of the discrepancy criteria in the identification of SLD was based on a number of difficulties,
including: lack of consistency in definitions and application (the lack of a universal
protocol resulted in wide variations in the actual discrepancies used); an inherent bias
towards the extremes (older children and those with higher IQs were more likely to
meet the discrepancy criteria than younger children and those with lower IQs); use
of a failure-based model; Matthew effects (poor readers acquire cumulative deficits
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lowering overall IQ; Stanovich, 1986); and lack of research support for the discrepancy criteria (Stanovich, 1991).
As a result, the latest revision of the law (IDEA, 2004) added an alternative method
of identification for SLD, termed response to intervention (RTI), which allowed for
the option of identification of SLD based on the child’s failure to respond to a scientific,
research-based intervention (Federal Register, 2006, 300.307(a), p. 46789).
Response to intervention (RTI) The proposed RTI system met with criticism, including concerns that RTI fractured the connection between the historical definition
of SLD as a disorder in “the basic psychological processes” (IDEA, 2004) and the
proposed identification procedures which in essence ignored assessment of cognitive
processing deficits. According to Kavale (2005), “changes to the operational definition (RTI) without changes to the formal definition are indefensible” and result in a
“disconnect between the formal definition and the operational definition” (p. 553).
Semrud-Clikeman (2005) noted that RTI ignored intellectual ability which was crucial
to developing an appropriate intervention, and that RTI was a failure-based system of
identification based on a student’s failure to respond to intervention.
Current conceptualizations The Learning Disabilities Association of America (LDA)
responded to changes in legislation by preparing a working paper, the Expert Panel
White Paper (LDA, 2010), based on responses from 56 professionals recognized by
their peers for expertise in the area of SLD. The report addresses altered identification
procedures for SLD which allow for bypassing consideration of the cognitive nature of
the disorder in the decision-making process, and for determination of lack of achievement based on age or grade level criteria, rather than ability. The report suggests a
number of recommendations, including: strengthening identification procedures to
match the definition of SLD; recognition that students with SLD require individualized interventions, not more intensive general interventions (i.e., more of the same);
and the use of cognitive and neuropsychological assessments to identify strengths and
weaknesses for the purposes of developing interventions based on the learning profile.
Specific types of learning disabilities
Prevalence rates for SLD have been estimated to be somewhere between 2% and 10%
of the population (APA, 2000). The following discussion will focus on five different
types of disabilities, evident in disabilities in reading, writing, mathematics, nonverbal
learning, and motor skills (coordination, including handwriting). A summary of these
variations is available in Table 8.1.
Specific reading disability (dyslexia)
Traditionally, children with a reading disability (dyslexia) experience a significant
discrepancy between general cognitive ability (IQ which is usually in the average
range or above) and achievement in reading (which is significantly below IQ, by
about 2 standard deviations). The disability is not the result of inadequate teaching,
impaired sensory processes (vision or hearing problems), or second language factors.
Reading problems can occur in decoding words (the recognition of sound/symbol
association), and/or reading comprehension (understanding the meaning). Either or
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Table 8.1
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Types of specific learning disability
Disability
Nature of disability
Associated problems
Dyslexia
Reading disability
Dysgraphia
Disability in written
expression
Dyscalculia
Disability in
mathematics
Nonverbal learning
disability
Disability in
visuospatial areas
Dyspraxia
Developmental
coordination
disorder (DCD)
Problems with decoding, comprehension,
fluency of reading. Associated problems may
also be evident in spelling and speaking.
Problems in executing written responses,
organizing information, sequencing ideas,
grammatical structure, and handwriting.
Problems with “number sense,” estimation of
quantity, money, spatial configurations,
concept of time, recall for number facts, and
problem solving using numbers.
Problems associated with right hemisphere
dysfunction, evident in poor mathematics
ability, poor interpretation of symbols
(numbers, graphs, charts), and poor sense of
proprioception (sense of body in space),
balance, and social pragmatics.
Problems with fine and gross motor skills,
physical coordination, posture, eye–hand
coordination, balance, and manual dexterity.
both of these processes can significantly influence reading fluency (the ability to read
with appropriate speed and in an uninterrupted manner).
Definition of reading disability
Dyslexia (a specific reading disability) is defined as:
a specific learning disability that is neurobiological in origin. It is characterized by difficulties with accurate and/or fluent word recognition and by poor spelling and decoding
abilities. These difficulties typically result from a deficit in phonological component of
language that is often unexpected in relation to other cognitive abilities and the provision
of effective classroom instruction.
(Lyon & Shaywitz, 2003, p. 2)
Although identification of low academic achievement (in, for example, reading, written expression, or mathematics) is the hallmark of a SLD (Johnson, Humphrey,
Mellard, Woods, & Swanson, 2010), how intelligence and underlying cognitive processes influence the development and course of SLD remains an area of enquiry. In
their longitudinal study of 232 children in grades 1 through 12, Ferrer et al. (2010)
found that while typical readers evidence a bidirectional influence between IQ and
reading, compensated readers (who eventually master reading, but are not fluent readers) and persistently poor readers demonstrate a “disruption in the interconnection
between IQ and reading over time” (p. 99). Ferrer et al. (2010) suggest that in typical readers there is a naturally occurring feedback loop (coupling) between IQ and
reading, as reading opens the door for the acquisition of increased vocabulary and general knowledge which in turn enhances IQ. However, for those who are compensated
readers or persistently poor readers, the “Matthew effect” (Stanovich, 1986) takes over,
producing an ever widening gap between good and poor readers. Furthermore, poor
Problems of Learning and Attention
197
reading may also negatively impact the development of language and intellectual
functioning.
Characteristics of dyslexia are most evident in problems of accuracy in decoding
skills in the primary grades; however, by adolescence and adulthood, even if accuracy
improves, fluency issues (slow and labored reading) become the signature characteristic of dyslexia (Ferrer et al., 2010). Shaywitz and Shaywitz (2008, p. 1343) suggest
that fluency issues justify the need for extra time on “high stakes standardized tests
such as the SATs, GMAT, GRE” since students with dyslexia are at “a disadvantage
compared to nondyslexic peers.”
Nature and course
Developmental characteristics Younger children may experience problems with
pre-reading skills, such as learning the alphabet; recognizing letters, numbers, or
shapes; word retrieval; and rhyming tasks. Reading instruction in the primary grades
may be halted due to the child’s inability to attach the correct sound to a letter, tendency to blend sounds together or confuse similar-looking words (mirror reading or
writing; for example, saw for was), or difficulty in sequencing letters correctly. Because
there are wide variations in skills and abilities due to different levels of exposure to
reading materials, some children may demonstrate lags and then “catch up,” while
others continue to fall further and further behind. By third grade, reading problems
become more noticeable, and in subsequent grades children with dyslexia will often
begin to use avoidance to escape the embarrassment of reading out loud. As reading demands increase, children may become overwhelmed with the pace of reading
demonstrated by their peers. If they are able to master decoding and word recognition, they may not be able to read for comprehension due to problems processing
information in a way that retains the sequence of information in a meaningful way.
Other difficulties that can be exhibited by children with dyslexia include problems
following directions and responding to questions in an organized and timely manner.
Children and adolescents with dyslexia also often exhibit executive functioning
deficits (working memory, self-monitoring, self-regulation (inhibition), and metacognitive skills), the identification of which can be instrumental in developing successful
interventions (Semrud-Clikeman, 2005).
Prevalence and etiology
Prevalence The prevalence rates for dyslexia range from 5% to 17%, depending on
the definitions used and the populations sampled (Ferrer et al., 2010). Although the
majority of sources report dyslexia accounts for 80% of all SLD (APA, 2000; Lerner,
1989), Mayes and Calhoun (2007) have challenged this assumption based on results
from a clinical population (containing 485 children) that revealed written expression
(92%) as the most common form of SLD.
Genetic influences Dyslexia is a highly heritable disorder with at least half (50%) of
the variance in the disorder explained by genetics (Olson & Byrne, 2005), with recent
investigations focusing on the influence of DCDC2 contained on chromosome 6
(Schumacher, Anthoni, Dahdou, Konig, & Hillmer, 2006). Between 23% and 65% of
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children with dyslexia have parents with dyslexia, while 40% of children with dyslexia
have a sibling with the disorder (Pennington & Gilger, 1996). Although more boys
are referred and identified, there are a significant number of girls who also are dyslexic
(Flynn & Rahbar, 1994).
Neurological systems and dyslexia Several studies have pinpointed deficits in
phonological processing in children with dyslexia, and interventions targeting weaknesses in the area have met with success (Torgesen, 2000). Other cognitive processing
deficits associated with dyslexia include: expressive and receptive language, processing
speed (Flanagan, Ortiz, Alfonso, & Dynda, 2006; Pennington, 2009), and verbal
working memory (Swanson, 2009). In their meta-analysis of 32 studies investigating
cognitive processes associated with SLD, Johnson et al. (2010) suggest that based
on the magnitude of effect sizes, future studies should focus on: working memory,
processing speed, executive function, and receptive and expressive language.
Using functional magnetic resonance imaging (fMRI) technology, researchers have
found that normal readers access three areas of the left hemisphere of the brain
to accomplish specific tasks: phoneme recognition (anterior system: left frontal
gyrus); mapping sound to letter form (posterior system: parietotemporal region);
and storage of sight vocabulary for rapid identification in the future (posterior system: occipitotemporal region). The occipitotemporal region, also termed the visual
word-form area (VWFA; Cohen et al., 2000), is an integral component of reading fluency. Developmentally, neural pathways for reading mature from the posterior
regions (visual perceptual processes, letter and word naming) to the frontal regions
(activated in reading comprehension), and from the right hemisphere to the left. However, individuals with dyslexia show low activation of the left posterior systems and
compensate by using both the left and right anterior systems, and the right posterior
VWFA (Shaywitz & Shaywitz, 2008). See Figure 8.1 for an illustration.
Attention and dyslexia Based on the discrepancy criteria used, prevalence rates for
comorbid ADHD and dyslexia are reported to be as high as 38–45% (Dykman &
Ackerman, 1991). Reynolds and Besner (2006) have focused on the attentional
aspects of reading, and suggest that attention is crucial to the reading process and
essential to translating print into speech for fluent reading. The neurological system
that maintains attention, particularly the prefrontal cortex, is regulated by the release
of catecholamines (dopamine, norepinephrine). Compared to controls, children with
ADHD show less activity in the prefrontal and frontal cortex, caudate nucleus, cerebellum, and parietal cortex (Casey, Nigg, & Durston, 2007; Epstein et al., 2007).
The posterior parietal cortex plays a significant role in both the regulation of attention
and dyslexia through its connection to the prefrontal cortex. In this way, activation of
the prefrontal areas may serve to active the posterior reading systems. Shaywitz and
Shaywitz (2008, p. 1343) suggest that contemporary research has demonstrated that
“attentional mechanisms play a critical role in reading and that disruption of these
attentional mechanisms plays a causal role in reading difficulties.”
Assessment and treatment/intervention
Assessment An initial assessment for dyslexia includes an evaluation of reading achievement in decoding, fluency, and reading comprehension. Whether an
Problems of Learning and Attention
ANTERIOR SYSTEM
POSTERIOR SYSTEM
Cerebrum
Body
Movement
Parietal
and coordination Bodily Lobe
Sensations
Frontal
Lobe
Prefrontal cortex
(PFC) and frontal
lobes (attention,
planning)
Thought and
Consciousness
Speech
Hearing
Occipital
Memory for
Lobe
Speech Reading
Memory for Sight Visual
Sight
Images
Parietotemporal
region (word analysis)
Memory for Music
Smell
Broca’s area
inferior frontal gyrus
(articulation/word
analysis)
199
Temporal
Lobe
Pons
Occipitotemporal
region (word form)
Coordination
Medulla Oblongata
Cerebellum
Spinal Cord
Figure 8.1 Neural systems involved in reading. Normal readers access the left hemisphere:
an anterior system (inferior frontal gyrus) and posterior systems (parietotemporal region and
occipitotemporal region). Individuals with dyslexia compensate for poor processing in the left
hemisphere by increased activation of the inferior frontal gyrus and occipitotemporal regions in
the right hemisphere.
assessment should include measures of cognitive ability has been a matter of debate
among educators, researchers, professionals, and policy makers. As emphasized by
Johnson et al. (2010), the importance of identifying the underlying deficits in cognitive processes is at the basis of the definition of and eventual intervention for SLD.
In their paper, Johnson et al. (2010) recommend cognitive assessments for reading
disability (RD) are needed to detect:
r
r
r
r
r
normal psychometric intelligence;
below-normal achievement in reading;
below-normal performance in specific cognitive processes;
deficits in isolated cognitive processes that persist despite exposure to evidencebased instruction;
that cognitive processing deficits are not directly caused by environmental factors
or contingencies (e.g., low socio-economic status).
Intervention Although RTI has been suggested as the first line of intervention,
there is evidence from meta-analytic sources (Tran, Sanchez, Arellano, & Swanson,
2011) that children with higher IQ scores than reading scores are less responsive
to treatment than children whose IQ and achievement scores share the same lower
range. Furthermore, research shows that reading difficulties persist and do not subside
with time. According to Shaywitz, Morris, & Shaywitz (2008), this important finding
“should put an end to the unsupported, but unfortunately, too widely held notion that
reading problems are outgrown or somehow represent a developmental lag” (p. 470).
Shaywitz and Shaywitz (2008) questioned whether neural systems involved in reading could be malleable and change given the appropriate reading intervention. In an
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experiment involving dyslexic readers in the second and third grades, the researchers
demonstrated that given 50 minutes of daily individual tutoring on phonemes and
sound symbol associations, subjects increased brain activation patterns similar to typical readers.
Based on a meta-analysis of empirically supported interventions for reading, the
Report of the National Reading Panel (2000) highlights five components that are
essential to any reading instruction program: phonemic awareness, phonics, fluency,
vocabulary, and reading comprehension.
Early intervention/prevention Programs that target children in kindergarten and
first grade and focus on phonemic awareness and the meaning of text have been
successful in reducing the rates of at-risk students to less than 5% (Shaywitz, Morris,
& Shaywitz, 2008). These programs have offered instruction in the classroom (Fuchs
& Fuchs, 2005), or pullout programs (Vellutino, Scanlon, Small, & Fanuele, 2006),
or some combination of the two (Vaughn, Linar-Thompson, & Hickman, 2003).
Later interventions Results with older children and adolescents are not as promising
as those for early intervention, and although accuracy may be improved considerably,
fluency often remains a serious issue. Programs which have been successful in improving accuracy include those focusing on direct instruction (phonological analysis) and
metacognitive strategies (Lovett, Barron, & Benson, 2003).
The majority of programs that address fluency issues use a repeated readings
approach (Meyer & Felton, 1999) which involves reading a passage repeatedly, timing
the speed of reading and accuracy by recording the reading on tape. Repeated readings with scaffolding (support by peers or teachers) have been successful in improving
fluency for children with dyslexia (Kuhn & Stahl, 2003). Comprehension-focused
instruction often emphasizes strategies and critical thinking skills related to reading
for meaning.
Disorders of written expression (dysgraphia)
Compared to research on reading disorders, investigation concerning written expression has lagged far behind (Hooper, Swartz, Wakely, de Kruif, & Montgomery, 2002),
especially regarding the nature of neurocognitive processes involved in executing written tasks.
Definition of disorders of written expression Part of the difficulty in amassing information about problems in written expression is the difficulty in defining and assessing
the problem area. According to the DSM (APA, 2000), a disorder of written expression includes the “composition of written texts (e.g., writing grammatically correct
sentences and organized paragraphs,” which may include multiple spelling errors
and poor handwriting but excludes “a disorder in spelling or handwriting alone, in
the absence of other difficulties of written expression” (p. 56). Measurement of the
discrepancy between ability and achievement in written expression is similar to the
criteria used for measurement of achievement in reading and includes “an individually
administered standardized test, or functional assessment.” The reason for inclusion
of the “functional assessment” is that evaluation may include a review of samples of
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a child’s written schoolwork. Furthermore, the DSM states that “if poor handwriting is due to impairment in motor coordination, then a diagnosis of developmental
coordination disorder should be considered” (APA, 2000, p. 56).
Nature and course Disabilities in written expression may manifest in a number of
different errors, including: sentences with punctuation and grammatical errors; poor
organizational presentation; and delays in initiating written responses. Early warning
signs may be evident in poor ability to copy words correctly, or in letter reversals or
transpositions; however, identification can be delayed since demands for written work
are often minimal in the first grade program, and delays may remit in some children.
Often children with problems in written expression experience reading disorders,
mathematics disorders, or both (Mayes & Calhoun, 2007). The process of writing is
complex and involves a number of stages and composite skills, including: planning,
generating content, organizing the composition, translating content into written language, and revising and improving the writing (Reid & Ortiz Lienemann, 2006).
In their study of the writing process, Berninger and Rutberg (1992) found that
young children’s early fine motor planning and control were related to success or
lack of it in later written expression. Other neurological factors and executive functions that have been implicated in the writing process include: memory, attention,
graphomotor output, sequential processing, and higher order verbal and visual-spatial
functions (Hooper et al., 2002). In particular, executive functions associated with the
prefrontal cortex have been of increased interest to researchers investigating written
expression. Given this direction, it is not surprising to see a number of studies that have
investigated written expression in children with ADHD which is primarily a disorder
of executive function. Children with ADHD have been found to have significantly
more problems in transcription skills (handwriting, copying) and spelling than their
non-disabled peers (Imhof, 2004; MTA Cooperative Group, 1999).
Prevalence and etiology According to Mayes and Calhoun (2007), prevalence rates
for problems of written expression have been underestimated, especially in clinical
populations, where written problems were the most prevalent form of learning disability. Developmentally, prevalence rates for writing problems escalate from 1.3–2.7%
in primary-grade children (Berninger & Hart, 1992), to 6–22% of middle school children (Hooper et al., 2002). Although research into the root causes of dyslexia has
been prolific, few studies have explored the etiology of disabilities in written expression, and, as a result, little is known about potential causes of the disorder.
Assessment and intervention
Assessment Identification of written expression problems can depend on the assessment instrument used. Mayes, Calhoun, and Lane (2005) compared results from
the Woodcock-Johnson (1989) Written Language Subtests (which measures achievement for the production of single words and single sentences) with results from the
Wechsler Individual Achievement Test (WIAT; Psychological Corporation, 1992)
Written Expression Subtest (which assesses compositional writing skills). While the
Woodcock-Johnson identified 35% of children as having significant writing problems, the WIAT identified 78% of the sample as having significant problems in written
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expression. The authors suggest that compositional writing is a more complex task and
should be assessed in determining whether an individual has significant problems in
written expression.
Intervention Direct instruction in writing strategy (planning) using prompts and
mnemonics with guided feedback and self-regulatory procedures can improve the quality of writing for students with writing disabilities (Vaughn, Gersten, & Chard, 2000;
Graham, Harris, & Larsen, 2001). In students with ADHD and comorbid writing
disabilities, Reid and Ortiz Lienemann (2006) found that the use of a Self-Regulated
Strategy Development (SRSD) model, stressing goal setting and self-monitoring, was
instrumental in increasing the amount and quality of written work produced by children with ADHD who had comorbid writing problems.
Accommodations that circumvent the writing process can also be beneficial for
children with severe writing problems and who would otherwise not be able to disseminate their ideas. For these students, dictated passages have been found to be
superior to written essays (Graham, Harris, & Larsen, 2001) and students may also
benefit from using speech recognition software (Reid & Ortiz Lienemann, 2006), or
keyboards and word processors (Graham et al., 2001; MacArthur, 2000). Accommodations such as providing access to class notes, use of a scribe, study guides, outlines,
and modified test taking through increased time or reduced written content (filling
in blanks, multiple choice, oral exams) can also increase students’ opportunities for
academic success (Reid & Ortiz Lienemann, 2006).
Specific mathematics disability/mathematics learning disability
(MLD/dyscalculia)
Definition Children with dyscalculia have limitations in mathematical areas involving “number sense,” problem solving, and fluency in retrieving mathematical facts
(Geary, Brown, & Samaranayake, 1991). Research into cognitive processing deficits
that impact performance in mathematics are not as readily available as those in reading;
however, deficits have been suggested in a number of areas associated with executive
functions, including: visual and verbal working memory, processing speed, and attention (Fuchs et al., 2005; Geary, 2004; Swanson & Jerman, 2006).
Nature and course Geary, Hamson, and Hoard (2000) suggest that problems in
charting the course and in the identification of MLD are compounded by variability
in performance and the types of assessment instruments used. For example, some
students may show low achievement levels in one grade but average levels in another.
The variability may be related to the specific concept taught (e.g., some may struggle
with division, others with fractions), or other factors (such as emotional difficulties).
Furthermore, instruments that use composite scores for evaluating mathematical performance may not be sensitive to severe gaps and weaknesses in specific areas. Compared to those with intermittent performance, children who have MLD experience
mathematics problems as a result of cognitive or memory deficits, which are persistent,
and often treatment-resistant. These problems are evident in deficits in calculation
fluency (Gersten, Jordan, & Flojo, 2005) and early acquisition of number sense (the
ability to estimate, judge quantity, and sequence).
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Prevalence and etiology Estimates suggest that 5–10% of children enrolled in the
educational system will meet criteria for MLD (Barbaresi, Katusic, Collagin, Weaver,
& Jacobsen, 2005; Shalev, Manor, & Gross-Tsur, 2005). The two main approaches
to understanding MLD involve a domain-general approach and a domain-specific
approach (Mazzocco, Feigenson, & Halberda, 2011). The former approach seeks
to answer questions about how and why some children develop MLD and focuses
on cognitive systems and executive functions such as phonological skills, working
memory, long-term memory, visuospatial processing (Geary, 1993), and genetic predispositions to MLD (Plomin & Kovas, 2005). Other researchers focus on specific
processing deficits, such as number processing skills or “number sense,” and how
these skill deficits relate to MLD (Dehaene, Piazza, Pinel, & Cohen, 2003; Mazzocco, Feigenson, & Halberda, 2011).
Findings from domain-general research Heritability rates for general mathematics
disability (43%) and reading disability (47%) suggest far more genetic than environmental influence (Kovas et al., 2007; Plomin & Kovas, 2005). Plomin and Kovas
(2005) suggest a “Generalist Genes Hypothesis” of learning abilities and disabilities
based on twin studies that have demonstrated high genetic correlations (averaging
0.68) between reading and mathematics ability, suggesting extensive genetic overlap. However, since the correlation is not perfect, Kovas, Harlaar, Petrill, and Plomin
(2005) estimate that approximately a third of the genetic variance in mathematics is
independent of reading and general intelligence (g).
Inherent in MLD are processing problems, such as problems of executive functions
(attention, short-term memory) and deficits in visual-spatial functioning, that may
contribute to poor alignment of numbers or faulty understanding of place value
systems, or charts and maps (Geary, 2003). Children who repeatedly use their fingers
for counting may be using this strategy to make up for deficits in working memory
(Geary, 2000).
Findings from domain-specific research Mazzocco, Feigenson, and Halberda
(2011) investigated deficits in the Approximate Number System (ANS) in 71 ninth
graders. The ANS is an implicit system that is universally evident at an early age
in normally developing children and involves the use of “number sense” in making
judgments about the relative size or quantity of one array compared to another.
In their paper describing the process, Mazzocco et al., (2011) use the example of
“selecting a checkout line” in a store based on the number of people lined up.
Results from their study suggest that children with MLD demonstrated significantly
poorer ANS acuity compared to peers without MLD, even when controlling for more
general cognitive abilities.
Assessment and intervention/prevention There has been a consolidated effort to
develop and research valid early screening measures for mathematics proficiency
(Gersten, Jordan, & Flojo, 2005). The Number Knowledge Test (Okamoto & Case,
1996) is a screening device that provides good predictive validity for early skills in
basic mathematical concepts, operations, number sense, and counting.
Because mathematics is a cumulative area of knowledge, emphasis has focused on
early identification and prevention. Morgan, Farkas, and Wu (2011) recently investigated the learning trajectories for a large sample of children (7400) from kindergarten
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to grade 5, in children with LD (specific learning disabilities, in reading and/or
mathematics), SLI (speech and language impairment), and controls. Results revealed
Matthew effects (i.e., the poor get poorer) for children with MLD but not for those
with reading disabilities, suggesting the importance of early intervention/prevention
in this population.
Results from early intervention programs and prevention initiatives have found that
significant time and practice must be devoted to strengthening mathematical concepts.
For example, in one study, small-group first grade intervention, four days per week for
15 minutes per session over the course of 18 weeks, yielded no significant effect on
mathematics ability for students in the program (Bryant, Bryant, Gersten, Scammacca,
& Chavez, 2008). However, in a follow-up study, extending the time to 20-minute
sessions four days per week over the course of 23 weeks did reveal a significant positive
effect (Bryant, Bryant, Gersten, Scammacca, Funk et al., 2008). Other studies have
had mixed results. For example, Fuchs et al. (2006) found that their computer fact
retrieval system increased student facility for addition facts, but not subtraction. In
their review of intervention programs, Gersten et al. (2005) stress the importance
of assessment and intervention in areas of discrimination of quantity (such as using
number lines) and identification of numbers.
Nonverbal learning disabilities (NLD)
Definition Rourke and colleagues (Rourke, 1982, 2000; Rourke, Hayman-Abello,
& Collins, 2003) have distinguished a type of learning disability which is distinct from
other learning disabilities due to an emphasis on the nonverbal aspects of information
processing, compared to problems resulting from a basic phonological processing
disorder (BPPD) associated with reading and writing disabilities. As a result, children
with a nonverbal learning disability (NLD) will evidence right hemisphere dysfunction (Mattson, Sheer, & Fletcher, 1992) and problems in visual-spatial processing,
unlike those with BPPD who demonstrate deficits in the left hemisphere. The syndrome is characterized by “significant primary deficits in some dimensions of tactile
perception, visual perception, complex psychomotor skills and in dealing with novel
circumstances” (Rourke et al., 2002, p. 311). The disability has also been referred to
in the literature as developmental right-hemisphere syndrome (Gross-Tsur, Shalev,
Manor, & Amir, 1995) and visuospatial learning disability (Cornoldi, Venneri,
Marconato, Molin, & Montinari, 2003).
Nature and course Characteristics of children with NLD may include clumsiness,
poor coordination, and a poor sense of spatial awareness, especially of their body in
space and social/personal space. In their study of children with NLD, Gross-Tsur et al.
(1995) found the vast majority experienced problems with slow processing speed both
cognitively and motorically (80%), graphomotor impairment (90%), and dyscalculia
(67%). Visual memory, including immediate memory for faces, was also impaired for
children with NLD (Liddell & Rasmussen, 2005). In their study of measures of social
perception, Semrud-Clikeman, Walkowiak, Wilkinson, and Minne (2010) found that
children with NLD and Asperger disorder evidenced impairment in reading social
and emotional cues and were more likely to exhibit sadness and social withdrawal
compared to controls. Studies have demonstrated that children with NLD experience
many deficits in social functioning, including poor ability to understand social rules,
pragmatic language, eye contact, and facial expressions (Gross-Tsur et al., 1995).
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Reluctance to engage in novel situations or tasks, and social withdrawal, can have
negative long-term outcomes for individuals with NLD, resulting in increased risk for
depression and suicide (Rourke, 1995). Comorbid ADHD is not uncommon in those
with NLD.
Prevalence and etiology The prevalence of NLD is rare (0.1%); however, cases may
remain undiagnosed or misdiagnosed (e.g., as Asperger disorder) due to the lack
of understanding or familiarity with of this type of learning disability. Unlike other
learning disabilities, the male to female ratio is equal for NLD. While other forms of
learning disabilities have a strong genetic component, NLD is related more to brain
structure and function.
The white matter model
According to Rourke (1982, 1995), the etiology of NLD is best explained by
deficits (destruction or dysfunction) in the white matter that impairs the ability
to access the right hemisphere to integrate information cross-modally.
Assessment and treatment/intervention Given the neurological basis for NLD, a neuropsychological examination is recommended which evaluates functioning in a wide
range of areas tapping motor and psychomotor functions, including: grip strength, eye
tracking, visual-spatial organization, and other neuropsychological functions. Assessment of cognitive ability, problem solving, and set shifting (category test), as well as
academic and behavioral evaluations, are also recommended. Cornoldi et al. (2003)
have developed a visuospatial questionnaire to assist in the identification of students
with visuospatial disabilities which may also be of value in identifying NLD.
It is important for intervention programs to target weak academic areas (especially mathematics skills) as well as social challenges facing children with NLD. Direct
instruction in social pragmatics (social skills, social communication, emotion recognition) can assist children to improve social competence. The majority of children
with NLD (72%) will experience significant math difficulties both in calculation and
problem solving (Rourke, 1995, 2000), and many will need practice to improve handwriting skills.
Dyspraxia (developmental coordination disorder)
Definition Dyspraxia and developmental coordination disorder (DCD) are terms
that have been used interchangeably to refer to problems children experience with
posture, movement, and coordination. While dyspraxia is more commonly used in the
United Kingdom, in the United States DCD is the term most frequently used.
Historically, several terms have been used to describe children who exhibit movement
difficulties, such as “congenital clumsiness,” “child or developmental dyspraxia”
(Vaivre-Douret et al., 2011), or developmental coordination disorder (DCD). The
term DCD was introduced in the DSM-III-R (APA, 1987) and is the only version that
is supported by diagnostic criteria. Overall, it is the most widely used term (Sugden,
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Kirby, & Dunford, 2008). Children with DCD satisfy two inclusionary (A, B) and
two exclusionary criteria (C, D):
A. The ability to perform tasks requiring motor coordination is significantly below
the norm.
B. The disturbance significantly impedes activities of daily living or academic achievement.
C. The disturbance is not due to a medical condition (e.g., cerebral palsy).
D. If IDD is also present, the disturbance is beyond what would be expected given
the IDD. (APA, 2000, p. 58)
Disturbances of motor coordination may include: delay in motor milestones
(crawling, walking), tendency to drop items, general “clumsiness,” and poor performance in athletics or academics due to poor handwriting. There are high rates
of comorbidity among children with DCD and developmental dyslexia, ADHD,
SLI, and ASD (Sugden et al., 2008). After conducting a substantive review of the
research concerning dyspraxia and DCD, Gibbs, Appleton, and Appleton (2006)
state that: “the terminology of coordination disorders has been confused but in practice dyspraxia and DCD should be regarded as synonymous” (p. 537).
Dyspraxia versus apraxia
While the term dyspraxia refers to the failure to develop the ability to perform
age-appropriate fine or gross motor skills, the term apraxia is used in adult
populations to refer to the loss of function previously acquired (e.g., loss of
movement through stroke).
Currently, the DSM does not consider DCD as a learning disorder, per se, but as a
motor skills disorder, and states that when considering disorders of written expression,
“if poor handwriting is due to impairment in motor coordination, a diagnosis of DCD
should be considered” (APA, 2000, p. 56). However, given the impact of the disorder
on learning and achievement, for purposes of this book, DCD will be discussed along
with the other learning disorders.
Nature and course Children with DCD have difficulties planning, controlling, and
coordinating motor activities in the absence of any neurological or physical condition
(Bowens & Smith, 1999). Recent investigations have found that in children with
ADHD, comorbidity rates with DCD can be as high as 50% (Kadesjo & Gillberg,
1998), leading some to suggest the existence of a combined disorder, atypical brain
disorder (Gilger & Kaplan, 2001), or deficits in attention, motor control, and perception (DAMP; Gillberg, 1992). However, recent investigation of cognitive profiles of
children with ADHD and comorbid ADHD and DCD reveal that while those with
ADHD alone do not demonstrate deficits in visuospatial ability, those with DCD
performed significantly weaker on the Perceptual Reasoning Index of the WISC-IV
compared to individuals with ADHD alone, leading researchers to suggest that the
two disorders have different etiology (Loh, Piek, & Barrett, 2011).
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Developmentally, children with DCD often demonstrate a history of delayed motor
milestones, poor ability to dress themselves (buttons and shoe laces), poor ability to
catch or throw a ball, and immaturities in art work (cutting, coloring). In primary
school, motor skills will continue to be delayed with slow and labored attempts at
handwriting and copying from the board.
Perceptual reasoning and intelligence
The Wechsler Intelligence Scale for Children (WISC-IV; Wechsler, 2002) has
four major scales that are used to derive an overall IQ score, namely: Verbal Comprehension, Perceptual Reasoning, Working Memory, and Processing
Speed. Perceptual reasoning involves the ability to derive solutions to problems
based on visual conceptual reasoning and the analysis and synthesis of visual
information (such as reproducing block designs), and working with complex
visual designs (matrix reasoning).
Prevalence and etiology It has been estimated that as many as 6% of children (five to
11 years of age) may meet criteria for DCD (APA, 2000). The exact cause of DCD
is not known but several suggestions have been made to account for central nervous
system dysfunction, including: premature birth, impairment in the dominant cerebral
hemisphere, sensory integration disorder, or birth complications, such as anoxia or
hyponoxia (Vaivre-Douret et al., 2011). Pinpointing the origins is further complicated due to bidirectional influences from biological, cognitive, and behavioral facets
of the disorder (Barnett, 2008). Although DCD has been associated with the development of internalizing behaviors in older children and adolescents (Cantell & Kooistra,
2002), more recent reports suggest that signs of internalizing problems in this population may be evident as early as three and four years of age (Piek, Bradbury, Elsley,
& Tate, 2008). Sequences of genetic codes for dopamine receptors DRD1–DRD5
and dopamine transporter DAT1 that have been identified in children with ADHD
have also been uncovered in those who have comorbid ADHD and DCD. Piek et al.
(2008) found that individuals with comorbid ADHD and DCD had significantly
higher depression scores than those with either disorder in isolation. Furthermore,
studies of students in college and university with motor difficulties have found that 50%
reported continued handwriting difficulties as a major source of difficulty for them,
while 52% also reported problems in areas of executive functioning, such as organizational skills, time management, and decision making (Kirby, Sugden, Beveridge, &
Edwards, 2008).
Assessment and treatment Although it is beyond the goals of this book to provide
a review of potential assessment and treatment techniques that can be applied to
DCD, interested readers are urged to read Barnett’s (2008) article which provides an
excellent summary of screening and assessment tools for DCD.
According to Sugden et al. (2008), challenges for the future will be to investigate
the needs of adolescents and adults who are attending higher education, and how to
assess DCD appropriately in these populations who may require disability services in
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order to be academically successful. Since a diagnosis of DCD requires the assessment
of motor skill deficits, the overall goals of occupational therapists are often centered
on targeting areas of sensorimotor impairment for intervention. However, Sugden
et al. (2008) emphasize the importance of targeting “participation” as an overall goal
for children with DCD, within a more ecological framework, engaging students in
areas of schoolwork, recreational activities, and self-care tasks.
Problems of impulsivity, hyperactivity, and inattention
Attention deficit hyperactivity disorder (ADHD)
Definition There is global consensus that extreme forms of impulsivity, overactivity,
and inattention constitute features of a disorder which can cause significant impairment
in functioning (International Consensus Statement on ADHD, 2002). However,
while the ICD-10 (WHO, 1993) defines the syndrome of hyperkinetic disorder
(HKD) using a narrow set of parameters, the DSM (APA, 2000) classifies attention
deficit hyperactivity disorder (ADHD) as a more broadly defined disorder with
three variations: inattentive, hyperactive-impulsive, or combined subtypes. Both
systems require symptoms to be pervasive (evident in two different situations; for
example, home and school), although for the ICD-10, full criteria must be met in
both situations. The disorder is persistent with onset usually prior to five (ICD-10)
or seven years of age (DSM).
The ICD-10 defines HKD as one disorder comprised of symptoms of inattention
and overactivity, while the DSM defines three versions of the disorder depending on
whether conditions are met for inattentive type (six of nine inattentive symptoms),
hyperactive-impulsive type (six of nine hyperactive-impulsive symptoms), or a combined type (meeting criteria for both the inattentive and hyperactive-impulsive type).
Conceptual differences between the ICD-10 and DSM
The major conceptual difference between these two classification systems is
that the ICD-10 does not recognize the inattentive subtype or the hyperactiveimpulsive subtype. The combined subtype is closest to the diagnostic criteria
for HKD; however, while the DSM requires that symptoms are pervasive across
more than one situation (e.g., home and school), the ICD is more stringent in
requiring that the full criteria must be met across two different situations.
Although symptoms are similar for both classification systems, differences in criteria
have resulted in variations in prevalence rates. Furthermore, the ICD-10 discourages comorbidity of HKD, other than within the confines of hyperkinetic conduct
disorder, while the DSM emphasizes that high rates of comorbidity exist for ADHD
with other disorders (ODD, CD, anxiety and mood disorders, and DCD).
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Nature and course
Birth to toddler period Parent reports of infant patterns of excessive activity, poor
sleep habits, irritability, and being difficult to soothe (Barkley, 1998) have been associated with increased risk for ADHD. Diagnosis is difficult in the toddler period due
to normally high levels of activity and lower levels of self-control.
Preschool age (three to six years) By three years of age, children who do not
regulate behaviors and emotions as expected are seen as more demanding and stressful
than peers. As a result, they evidence increased problems in unsupervised situations
(Altepeter & Breen, 1992), and in relationships with peers, preschool teachers, and
parents (Campbell & Ewing, 1990).
School age (six to 10 years) Difficulties are more evident as children face increased
academic and social demands. Problems of inattention, distractibility, organization,
and task completion place children at greater risk for academic problems. Socially,
overactive and impulsive behaviors, intrusive behaviors, excessive talking, and noisy
play can be disruptive in social circles. Risk of accidental injury at this stage is evident
in bicycle accidents, pedestrian injuries, and head injuries (Barkley, 1998).
Adolescence Adolescents with ADHD are more likely to evidence the lingering
effects of inattention, evident in ease of distractibility and poor ability to sustain their
focus at a time when the educational setting is becoming more complex (multiple
teachers), is more demanding (increased workload), and requires more self-discipline
and organization.
Although individuals with ADHD are at a disadvantage for graduating from high
school (Barkley, Fischer, Edelbrock, & Smallish, 1990), increased recognition of the
potential impact of ADHD on academic performance over the past 30 years has
resulted in improvements in support services and modifications to programming for
children and youth with disabilities. As a result, there has been an increase in the
number of students with “hidden disabilities,” such as ADHD and learning disabilities,
who are now seeking admission to colleges across the United States (Wolf, 2001),
and the enrollment of college students with ADHD is steadily increasing (Shaw-Zirt,
Popali-Lehane, Chaplin, & Bergman, 2005). It has been estimated that 2–4% of the
college student population would meet criteria for a diagnosis of ADHD (DuPaul
et al., 2001; Weyandt, Linterman, & Rice, 1995). College students with ADHD
represent 20% of students in college who have disabilities and one-quarter of those
receiving support services (Guthrie, 2002; Henderson, 1999).
Adolescents and adults with ADHD are at risk for lower educational achievement,
increased unemployment or underemployment, problematic interpersonal relationships, and less stability of residence, and a higher incidence of psychiatric disorders,
substance use disorders, and antisocial behavior (Grenwald-Mayes, 2002). In adolescence, lack of academic success and concomitant social problems can lead to a
host of comorbid externalizing and internalizing problems (Biederman, Faraone, &
Lapey, 1992). One of the major tasks of adolescents is identity formation and the
development of a positive self-concept based on peer acceptance, gained through
increasingly refined social skills. However, adolescents with ADHD often experience
low self-concept and poor levels of acceptance from peers, and are vulnerable to bouts
of depression. Mannuzza and Klein (2000) found that children who demonstrate
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deficits in social skills and self-esteem continue to experience difficulties in these areas
throughout adolescence and adulthood.
Stimulant medication and future risk
Although parents often express concern that stimulant medication can be a
“gateway drug” leading to the abuse of other substances, research finds the
opposite to be true. Adults with ADHD who did not have the benefit of
stimulant medication are at greater risk for later substance abuse than those
whose ADHD was successfully managed, medically (Biederman, Wilens, Mick,
Spencer, & Faraone, 1999).
Prevalence and etiology
Prevalence Due to the narrower criteria, the ICD-10 identifies fewer individuals
with HKD, while the broader criteria of the DSM leads to the identification of more
individuals with ADHD (Foreman, Foreman, Prendergast, & Minty, 2001). Lee et al.
(2008) compared the predictive validity of the two systems and found only 11% out of
the 419 cases that met criteria for ADHD also met criteria for HKD due to the more
rigid criteria of pervasiveness in the ICD-10 (requiring the full criteria to be met in
more than one situation). The authors support previous results (Lahey et al., 2006)
suggesting that the ICD-10 criteria under-identify those with significant impairment.
However, a study conducted by the UK Office of National Statistics reported that
ADHD was the most common referral to specialist child and adolescent mental health
services (CAMHS) across the United Kingdom (Meltzer, Gatward, Goodman, &
Ford, 2000), while in the United States, it is reported that approximately 30–50% of
referrals involve children with ADHD (Barkley, 1998).
Although the majority of children who are diagnosed with ADHD (90%) have the
more obvious forms of the disorder (hyperactive-impulsive or combined hyperactiveimpulsive–inattentive type), children with the inattentive type are likely to be identified
much later, or remain undiagnosed. While lack of self-control (disinhibition) associated with hyperactive-impulsive and combined types is likely to improve with age,
inattention remains relatively stable over time (Hart, Lahey, Loeber, Applegate, &
Frick, 1995).
The disorder is more frequent in males than females with ratios ranging from 2:1
to 9:1 (APA, 2000, p. 90); however, research suggests that females with ADHD are
significantly more impaired than males with ADHD and controls in areas of psychosocial functioning, including: depression, anxiety, self-esteem, and overall stress levels
(Rucklidge & Tannock, 2001). Since 90% of those diagnosed with ADHD have either
the impulsive/hyperactive or combined type, it is possible that gender differences
among children may represent differences in type. Whether there are male/female
differences in the subtypes of ADHD symptoms continues to be an area of debate.
At least one study found females were twice as likely to have the inattentive type
(Biederman, Mick, & Faraone, 2002), although research with college students has
demonstrated significantly less gender disparity (Weyandt, Linterman, & Rice, 1995).
It is estimated that between one-third and two-thirds of children with ADHD will
continue to demonstrate ADHD symptoms throughout their lifetime (Wender, Wolf,
Problems of Learning and Attention
211
& Wasserstein, 2001), while approximately 2–6% of the adult population will meet
criteria for diagnosis (Wender, 1995).
Etiology Complex interactions between biological factors and environmental factors
are at the core of ADHD. There is high heritability, with 50% of parents with ADHD
having a child with the disorder (Biederman et al., 1995). One study demonstrated
that if children and parents shared high ADHD symptoms, the children demonstrated
no improvement in the program, suggesting that it may be necessary to treat the
parent prior to intervention, in cases such as these (Sonuga-Barke, Daley, Thompson,
Laver-Bredbury, & Weeks, 2001).
Brain structures and brain function
Modern technology, positron emission tomography (PET), magnetic resonance
imaging (MRI), functional magnetic resonance imaging (fMRI), and singlephoton emission computed tomography (SPECT) brain scans have focused on
three sites relevant to ADHD: prefrontal cortex (executive functions, planning
ability), cingulated gyrus (focusing of attention and response selection), and basal
ganglia (time perception).
Neurotransmitters The catecholamines (dopamine, norepinephrine, epinephrine)
are neurotransmitters that have been associated with attention and motor activity.
Medications that have been successful in treating the disorder, such as Dexedrine
(dextroamphetamine), Ritalin (methlyphenidate), and Cylert (pemoline), work to
increase the number of catecholamines in the brain (Barkley, 1998).
According to Barkley (1997), behavioral inhibition (the ability to inhibit a
response, interrupt a current response, or block a distractor) is an essential step that
allows sufficient time for higher functioning (executive functions) to take place. This
delay allows the necessary time to process information in four major areas: working memory (planning skills), internalization of speech (analysis), self-regulation
of affect (goal direction and sustained attention), and reconstitution (synthesis).
Individuals with ADHD, especially the hyperactive-impulsive variant, evidence poor
behavioral inhibition.
Video games versus homework
Why is it that children with ADHD can play video or computer games for
hours, yet cannot do homework? Barkley (1997) addresses the issue by distinguishing between sustained attention (effortful attention in a low interest
task, such as homework) versus contingency based attention (focusing on a
task that in inherently rewarding, such as a video game). Children with ADHD
have problems sustaining goal-directed behavior for low interest tasks that are
not rewarding.
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Assessment and treatment/intervention Assessment for ADHD can involve a number of different procedures depending on the professional involved. A family physician can diagnose the disorder based on an evaluation of symptoms and medical/developmental history. A psychologist may observe the child in the classroom,
have parents and teachers complete a number of behavioral questionnaires, and administer a battery of individual tests (of cognitive ability, executive functions, and academic
achievement), most of which have been previously discussed.
Treatment will vary based on the nature and severity of the problem, and the
child’s developmental level. Determining the correct type of medication and dosage
may be difficult and frustrating. In addition to stimulant medications that target the
catecholamines, Strattera, a selective norepinephrine reuptake inhibitor (NRI), has
recently been found effective in the treatment of ADHD.
Although medication is often the treatment of choice, there are times when medication either is ineffective or produces unwanted side effects. Alternative treatment
methods, such as behavior management programs, can be devised through observations at school and at home and by conducting a functional behavioral assessment
to target behaviors for intervention (e.g., to increase on-task behavior). Examples of
functional behavioral assessments are available in Chapter 5. Other classroom interventions that have been successful include peer tutoring and computer-assisted instruction
(DuPaul & Eckert, 1998; Hoffman & DuPaul, 2000). Parent training programs can
also improve parent management, help reduce parent stress, and increase positive
behaviors (Barkley, 1997; Forehand & McMahon, 1981).
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9
Externalizing Problems and
Disruptive Behavior Disorders
Chapter preview and learning objectives
Externalizing problems: an overview
Aggressive behaviors
Definition and types of aggressive behaviors
Bullying
Definition
Oppositional defiant disorder
Definition
Nature and course
Prevalence and etiology
Assessment and treatment/intervention
Disorders of conduct
Definition
Nature and course
Prevalence and etiology
Assessment and treatment/intervention
References
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Chapter preview and learning objectives
While internalizing problems are often subtle and covert, externalizing problems are
often disruptive and overt. In this chapter, the focus is on the continuum of aggressive
behaviors, beginning with normal aggressive responses (instrumental aggression) and
extending into those behaviors that have the capacity to inflict harm on others, in
a number of different forms, whether they involve bullying, relational aggression,
or reactive or callous acts of aggression. This chapter will provide readers with an
increased understanding of:
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the various forms of aggression and the severity of each type;
the etiology and prevalence of behavioral disorders;
the bio-psycho-social conditions that can precipitate and maintain aggressive
behaviors;
Clinical and Educational Child Psychology, First Edition. Linda Wilmshurst.
© 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.
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the qualitative and quantitative differences in the two major disruptive disorders:
oppositional defiant disorder and conduct disorder;
treatment and intervention programs that can assist in the management of behavioral disorders.
Externalizing problems: an overview
Early onset externalizing problems, such as aggressive, oppositional, and destructive behaviors, can increase a child’s risk for developing serious problems (such as
delinquency and conduct problems) later on (Campbell, 2002). In a study from the
Netherlands, externalizing behaviors were identified as early as 12 months of age (van
Zeijl et al., 2006). Harsh and inconsistent discipline practices, low parental monitoring, exposure to adult aggression, lack of family cohesion, and low parental warmth
have all been linked to increased risk for externalizing behaviors, while a sense of connectedness to family and school has been identified as a protective factor (Patterson,
Capaldi, & Bank, 1991; Resnick et al., 1997). The Conduct Problems Prevention
Research Group (CPPRG, 2011) has constructed a dynamic cascade model of the
development of antisocial behavior. In their model, which will be discussed shortly,
they outline several risk factors that are targeted in their longitudinal Fast Track Prevention Program for high-risk youth. The intervention program identifies and targets
eight risk factors for antisocial behavior:
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poor parent behavior management;
weaknesses in social cognitive information processing;
deficits in emotional coping skills;
poor peer relationships;
weak academic skills;
classroom environments that are disruptive and rejecting;
poor parental monitoring and supervision;
poor home–school relations. (CPPRG, 2011, p. 332)
Results have demonstrated that early starters (those who evidence conduct problems
early in life) are at the highest risk for life-long antisocial behaviors (Moffitt, 1993)
and that having a number of the risk factors above can have a multiplier effect. In an
early study, Rutter (1979) found that children who were exposed to two risk factors
were at four times the risk for developing a disorder, while having four risk factors
increased the risk tenfold. More recently, Herrenkohl, Maguin, and Hill (2000) found
that if a 10-year-old were exposed to six or more risk factors, they would be 10 times
more likely to engage in violent crime by 18 years of age, compared to peers who had
been exposed to only one risk factor.
Given the wide range of disruptive behaviors that might be subsumed under the
category of externalizing behaviors, it is not surprising to see that estimates for externalizing behaviors demonstrate considerable variability. As a result estimates of prevalence rates in community samples have ranged from 2% to 20% of the population
(Brandenburg, Friedman, & Silver, 1990; Offord et al., 1987). In a longitudinal
study of preschool children at two, four, and five years of age, Hill, Degnan, Calkins,
Externalizing Problems and Disruptive Behavior Disorders
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and Keane (2006) found that 11% of girls and 9% of boys demonstrated clinical levels
of externalizing behaviors. In this study, the authors found that inattention at two
years of age was predictive of later externalizing problems.
Physical abuse has been found to be a significant risk factor for externalizing behaviors, such as aggression (Lansford, Criss, Pettit, Dodge, & Bates, 2003), conduct disorder (Lynch & Cicchetti, 1998), and juvenile delinquency (Attar, Guerra, & Tolan,
1994). Family poverty and living in violent neighborhoods have also been found to
increase the risk of externalizing problems (Attar et al., 1994; Widom, 1989). Child
characteristics, such as social competence, having positive peer relationships, and good
social problem solving skills, have been found to be protective factors that reduce the
risk of developing externalizing problems (Ladd, Kochenderfer, & Coleman, 1996;
Lochman & Wells, 2002).
Aggressive behaviors
The importance of developing self-regulation and emotional control is an important
developmental milestone. While children who are fearful often over-control behaviors
to avoid situations that can heighten their arousal level (Kagan, Reznick, & Gibbons,
1989), children who are fearless often approach high-risk or emotionally charged
situations without hesitation (Kagan, 1997).
The high cost of high emotionality and low
emotion regulation
Rydell, Berlin, and Bohlin (2003) found that young children (five to eight years
of age) who demonstrated high levels of emotional arousal and low emotion
regulation often demonstrated poor social adaptation, regardless of whether the
emotion-inducing situation was positive or negative. In negative situations, they
were easily provoked to aggression, while in positive situations, their behaviors
escalated out of control.
Definition and types of aggressive behaviors Definitions of “aggressive” behaviors can
differ based on the degree to which intentionality is considered in the definition.
While some theorists may consider any act of force to constitute an act of aggression
(Cote, Vaillancourt, LeBlanc, Nagin, & Tremblay, 2006), others consider a behavior
to be aggressive only if there is an intent to harm another individual (Dodge, Coie,
& Lyman, 2006). Researchers who take a middle ground distinguish between two
forms of aggression, instrumental aggression and hostile aggression. Additionally,
hostile aggression can be further partitioned into two subtypes: acts of overt aggression (obvious forms of aggression, such as verbal threats, hitting, punching, pushing)
or acts of covert aggression (hidden and less obvious forms of antisocial behaviors,
such as lying, stealing, bullying). Overt forms of aggression can be exhibited as proactive aggression, motivated by the anticipation of a reward (Dodge & Coie, 1987;
Little, Jones, Henrich, & Hawley, 2003); or reactive aggression, a response to perceived threats or provocation. Proactive forms of aggression can include characteristics
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Subtypes of aggression
Table 9.1
Aggression: “an act of force”
Hostile: with intent to harm
Instrumental:
with intent to
obtain a goal
Overt
Covert
Hitting, punching, verbal
threats
Secretive, hidden
Proactive
(planned)
Reactive
(defensive)
Covert destructive:
Violations of property
Sub-type:
Callousunemotional
Sub-type:
Impulsive
Covert
non-destructive:
Status violations
Relational:
Purposeful
manipulations
targeting peer
groups
of callous-unemotional aggression (Frick, Cornell, Barry, Bodin, & Dane, 2003),
while reactive forms characteristically are represented by more impulsive and emotionally aggressive responses. Forms of covert aggression may include destructive acts of
property violation (vandalism, breaking and entering), non-destructive acts of status
violation (truancy, running away), or acts of relational aggression. See Table 9.1 for
a list of aggressive subtypes.
Aggressive response patterns have also been subtyped according to neurophysiological profiles, comorbidity, overt versus covert patterns of behaviors, and age
of onset.
There has been considerable research linking aggression to problems in social adjustment, such as peer rejection and social skills deficits, as well as associated problems
in areas of academic difficulties, externalizing problems, and depressive symptoms
(Barriga et al., 2002; Campbell, Spieker, Burchinal, & Poe, 2006). However, research
has only recently begun to examine whether outcomes differ for the various subtypes
of aggression, especially relational aggression. Compared to boys, females have been
found to engage in more relationally aggressive behaviors than males, who are equally
likely to use overt or relational aggression (Putallaz et al., 2007). Preddy and Fite
(2012) investigated the impact of relational versus overt aggression on four psychosocial outcomes (academic performance, social problems, depression, and delinquency)
in a community sample of 89 children (with a mean age of 10.4 years). Results revealed
negative associations between relational aggression and academic performance and
positive associations between overt aggression and delinquency. Furthermore, gender
differences were significant, with social problems being related to overt aggression in
males and relational aggression in females.
Instrumental aggression and hostile aggression The distinction between instrumental and hostile aggression is the nature of intent; instrumental aggression is goaldirected behavior that does not include an intent to harm another individual, while
the intent of hostile aggression is to inflict harm on another (Hartup, 1974). Instrumental aggression is thought to increase in the second and third years due to the
child’s increasing cognitive and social awareness of intentionality and engagement in
goal-directed behaviors (e.g., Campos et al., 2000); however, nonverbal or physical
aggression decreases with age after this time, likely due to increased awareness of social
Externalizing Problems and Disruptive Behavior Disorders
223
rules and ability to solve conflicts verbally. Studies have shown that for toddlers, the
use of physical aggression declines as their vocabulary increases (Dionne, Tremblay,
Boivin, Laplante, & Perusse, 2003).
In preschool populations, a common area of peer conflict which can result in acts of
instrumental aggression involves disputes regarding the possession of objects, such as
toys, and attempts to defend or retrieve these possessions. According to Friedman and
Neary (2008), this type of conflict is common because toddlers believe that ownership
rests with the child who first possesses the toy. Hay, Hurst, Waters, and Chadwick
(2011) observed the defensive responses of 200 infants and toddlers in a London
sample ranging in age from nine months to 30 months. Behaviors were coded as:
resistance (movement towards the object, gently trying to retrieve it); verbal or vocal
protests (crying, verbal persuasion), or physical force (tugging at the object, using
bodily force). Results revealed that developmentally, infants initially resisted when a
possession was taken, but engaged in more active and vocal defense with increased
age, and by two years of age were more likely than younger children to engage in
instrumental aggression. Hay et al. (2011) suggest that these results support findings
by Tremblay et al. (2004) of a peak in aggressive behaviors in toddlers at two years
of age, but add that the spike in aggressive behavior may be due to an increase in
instrumental aggression during this time. However, the authors also note that, similar
to previous studies, the use of physical force was not the most common strategy used
by toddlers, and that when used, the authors found no evidence of an intent to harm.
In studies that have looked at more hostile oriented aggressive patterns in early
childhood, several family characteristics evident in the first three years of life were
associated with increased risk for developing disruptive behavior disorders, including:
caregiver depression, avoidant attachment pattern, stress, lack of quality care giving,
and low socio-economic status (Aguilar, Sroufe, Egeland, & Carlson, 2000; Tremblay
et al., 1999). Lacourse et al. (2006) found that kindergarten children from low income
neighborhoods were at highest risk for deviant behavior in adolescence if they also
were hyperactive, fearless, and low in prosocial behaviors.
Reactive aggression versus proactive aggression Distinctions between reactive
and proactive aggression have been made regarding the intent and function of
the aggressive behavior. While reactive aggression refers to an individual’s defensive
response to a perceived threat or aggravation, proactive aggression refers to behavior
that is planned or premeditated with a specific goal in mind, with the intention of
personal gain or influence (e.g., a bully who wants to obtain another child’s lunch
money). Research has found different environmental contexts can be associated with
these different aggressive patterns. While being subjected to harsh parenting practices may place a child at risk for reactive aggression (Dodge, Lochman, Harnish,
Bates, & Pettit, 1997), Xu, Farver, and Zhang (2009) found that Chinese children
who had an indulgent parent were at increased risk for proactive aggression. However, Vitaro, Barker, Boivin, Brendgen, and Tremblay, (2006) found that harsh and
inconsistent parenting practices can be associated with both types of aggressive behaviors, which may suggest that hypervigilant children may respond to an increased bias
towards threat, while proactive children may model the same behaviors. While studies
have found that children with reactive aggression are more socially isolated compared
to their proactive peers (Dodge et al., 1997), those with proactive aggression are
more likely to engage in delinquent behaviors in mid-adolescence (Vitaro, Gendreau,
Tremblay, & Oligny, 1998).
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Reactive and proactive aggression
From a theoretical perspective, reactive aggression is best supported by the
frustration aggression model (Berkowitz, 1978) and principles of negative reinforcement, since the aggressive act is intended to remove the perceived threat
(Vitaro et al., 2006). Proactive aggression is best explained by using Bandura’s
(1973) social learning model, where aggressive acts can be modeled and positively reinforced through rewards such as increased status, power, and control.
Studies have also found that the two forms of aggression can be evident in the
same individual, with approximately half of children demonstrating both forms of
aggression, and just 15% demonstrating only one form (Barker, Tremblay, Nagin,
Lacourse, & Vitaro, 2006; Crick & Dodge, 1996; Dodge et al., 1997).
Callous-unemotional (CU) aggressive traits In adults, it has long been recognized
that antisocial personality disorder includes a cluster of traits that characterize a lack
of empathy or guilt, a lack of remorse, and a tendency to use others for personal gain.
There is a continuum of severity within the disorder, with some individuals prone to
more violent and chronic patterns of psychopathy (Comer, 2010). Similarly, youth
who exhibit disruptive behavior disorders also represent a heterogeneous group, with
some children exhibiting traits which have been associated with more severe, negative,
and chronic outcomes.
Research has shown that children with behavior disorders who also exhibit CU
traits do not process emotionally-based information or recognize positive or negative
emotions in others, and exhibit less response at a physiological level to emotional
cues, than peers without CU traits. Furthermore, these children are non-responsive to
harsh parenting, engage in more high-risk behaviors, and demonstrate reduced activity in the amygdale which is responsible for emotional control, the fear response, and
interpretation of nonverbal emotional expressions (Jones, Laurens, Herba, Barker,
& Viding, 2009; Levenston, Patrick, Bradley, & Lang, 2000; Marsh, Gerber, &
Peterson, 2008). Furthermore, the genetic impact for children with behavior disorders and CU traits is significantly higher (0.81) compared to youth with behavior
disorders without CU traits (0.30), who are influenced more by environment than
heredity (Viding, Blair, Moffitt, & Plomin, 2005; Viding, Jones, Frick, Moffitt, &
Plomin, 2008).
Children who exhibit CU traits also demonstrate lower levels of behavioral inhibition and higher levels of behavioral dysregulation than other children with disruptive
behavior disorders (Frick et al., 2003). These children are more likely to exhibit
proactive aggressive patterns and decreased emotional reactivity, and to have a family
history of antisocial personality disorder (Hubbard, Smithmyer, & Ramsden, 2002).
Children with CU are most likely to exhibit early onset conduct disorder (CD) and
further discussion of this subtype will be revisited later in this chapter.
Aggression and neurophysiological profiles In addition to reduced activity in the
amygdale of individuals with aggression and CU traits, researchers have also found
immature P300 wave amplitudes in boys with a history of behavior problems involving
Externalizing Problems and Disruptive Behavior Disorders
225
Destructive
Covert destructive
Violations of property
Theft, vandalism,
fire setting
Overt destructive
Aggressive behaviors
Bullies, fights,
blames others,
cruel, spiteful
Covert
Overt
Covert non-destructive
Violations of status
Truancy, running away,
rule violations, swearing
Overt non-destructive
Oppositional
Touchy, stubborn,
argumentative, defiant,
annoying
Non-destructive
Figure 9.1 Overt/covert and destructive/non-destructive behaviors based on a meta-analysis
(Frick et al., 1993).
rule violations (Bauer & Hesselbrock, 2003). In a study of delinquent adolescents,
Teichner et al. (2000) found four clusters of deficits suggesting four different subtypes
of aggressive behaviors: verbal–left hemisphere deficits, subcortical-frontal deficits,
mild verbal deficits, and normals. The subcortical frontal cluster was associated with
significantly higher scores on the thought problems and delinquent behavior scales of
the Child Behavior Checklist (Achenbach & Rescorla, 2000). The biological basis of
antisocial behaviors will be revisited in the discussion of CD later in this chapter.
Overt versus covert acts of aggression In a meta-analytic study of 60 cases, Frick
et al. (1993) identified four clusters of symptoms along two factor analytic dimensions: overt and covert forms of aggression, and destructive or non-destructive acts.
Overt forms of aggression can be represented by destructive behaviors such as aggressive behaviors, bullying, fighting, blaming others, and being cruel and spiteful; or
non-destructive behaviors, such as being oppositional, touchy, stubborn, argumentative, defiant, and annoying. The overt behaviors are more symptomatic of behaviors
one associates with oppositional defiant disorder (ODD). On the other hand, covert
behaviors in this model include destructive acts such as property violations, theft,
vandalism, and fire setting, and non-destructive behaviors such as status violations,
truancy, running away, and rule violations. The latter characteristics are more closely
associated with symptoms of conduct disorder (CD). The four quadrants are displayed
graphically in Figure 9.1.
When considering the prevalence of overt acts of aggression, males are typically seen
as more aggressive than girls, and when considering severity of physical aggression,
males are also seen as more severe at all ages from four to 18 years (Crick, Casas, &
Mosher, 1997; Stranger, Achenbach, & Verhulst, 1997).
However, since Crick and Grotpeter (1995) introduced the concept of relational
aggression, researchers have investigated the possibility that females may be more
aggressive than initially thought, but that the form of this aggression may be different
from the overt acts of physical aggression that we normally associate with aggressive
behaviors.
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Relational aggression
According to Crick and Grotpeter (1995, p. 711) relational aggression involves
“harming others through purposeful manipulation and damage of their peer
relationship.”
Research since this time has suggested that the developmental trend for aggression
moves from overt acts of physical aggression, to overt vocal displays (due to increased
verbal skills), with relational aggression being more prevalent among older children
and girls, due to their increased understanding of social skills (Björkqvist, 1994).
While most studies support the fact that girls demonstrate more relational aggression
than boys from middle childhood (Björkqvist, Österman, & Kaukiainen, 1992; Crick,
1995, 1996), there are opposing views as well (Dodge et al., 2006). One study of
elementary school children found that relational aggression was related to depression
and peer rejection for girls, but not for boys, although there was a negative correlation
between prosocial behavior and relational aggression for all children in the study
(Crick, Casas, & Mosher, 1997).
Aggression and age of age of onset As previously noted, overt forms of aggression
peak between two and four years of age and decline after that period (Tremblay et al.,
1999). However, for some children, early starters, aggression remains a stable characteristic (Aguilar et al., 2000). Early signs that can predict the stability of aggressive
behaviors include: tendencies to be fearless (Kagan, 1997), or having a difficult temperament (Vitaro et al., 2006). Children who demonstrate high levels of emotionality
may have a lowered threshold for stimulation, and may react with a more intense
level of response. The combination of high emotionality and low emotion regulation within the context of externalizing behaviors can result in intensified emotional
arousal, reactivity, and escalation of disruptive behaviors (Rydell et al., 2003).
Later onset aggression is usually associated with more positive outcomes than early
onset, and is more often triggered by environmental conditions, such as inadequate
parental monitoring or affiliation with a deviant peer group (Patterson, Capaldi, &
Bank, 1991). According to Dodge et al. (1997), late starters are more likely to engage
in proactive forms of aggression or “socialized” aggression.
Bullying
Definition Bullying is an act of aggression that asserts power over an individual who
is repeatedly victimized (Olweus, 1995). Bullying can take several forms, including
overt acts of physical aggression, verbal aggression (threats, name calling), relational aggression (rumors meant to isolate an individual from their social group),
and, more recently, cyber bullying (text messaging, photos, or e-mails meant to
harass, embarrass, or ostracize the recipient). Due to an unprecedented rise in the
cases and awareness of bullying, there has been an associated rise in the number of
articles appearing in peer-reviewed journals about the topic. Although fewer than
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200 peer-reviewed articles on bullying could be found between 1980 and 2000, over
600 articles were published on the topic between 2000 and 2007 (Cook, Williams,
Guerra, Kim, & Sadek, 2010). Researchers have investigated the nature of bullying
(types of bullying), participants in the process (bullies and victims), and the efficacy of
school-based prevention programs (such as the Olweus Bullying Prevention Program;
Olweus, 1993). However, results concerning prevention programs have been disappointing, finding some mixed positive effects, but no overall effect (Bauer, Lozano, &
Rivara, 2007), or initial gains dissipating at 12-month follow-up (Jenson, Dieterich,
Brisson, Bender, & Powell, 2010).
Bullies, victims, and bully-victims Research has investigated the nature of bullying
and the outcomes to victims. Cook, Williams, Guerra, & Kim (2009) found three
groups of youth involved in the act of bullying: bullies, victims, and bully-victims.
Studies have confirmed that bullying increases as youth reach adolescence and that
it is a worldwide problem. Negative outcomes for the victims can be evident in
psychosocial concerns (loneliness, depression, low self-esteem, school avoidance) and
can even result in suicide attempts (Hawker & Boulton, 2000; Rigby & Slee, 1999).
Based on their meta-analysis of 153 studies of bullying, Cook et al. (2010) suggest that the majority of studies conducted in the past 30 years focus on individual
characteristics, without giving due recognition to the characteristics of the contextual
settings in which bullying occurs.
Context as a moderating variable in bullying
In their study of self-esteem and bullying, Gendron, Williams, and Guerra
(2011) found that school climate had a moderating effect on self-esteem. When
high self-esteem was evident within the context of a negative school climate,
it predicted bullying perpetration; however, when high self-esteem occurred
within a school climate that was positive, it predicted lower levels of bullying
perpetration.
In their meta-analysis, Cook and colleagues (2010, pp. 75–76) found a number of
characteristics related to bullying for each of the three groups:
Bully Youth in this category evidence comorbid externalizing and internalizing
symptoms, experience problems socially and academically, and have a negative view of
themselves, others, their community, and school. They have poor conflict resolution
skills, and are negatively influenced by peers. Family characteristics of bullies were
positive for family conflict, and poor parental monitoring.
Victims Youth who are victims share a number of characteristics with bullies, including a mix of externalizing and internalizing symptoms, poor social skills, and negative
self-view, although they are more likely to come from negative environments (family,
school, community) and are openly rejected and isolated by peers.
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Bully-victims This group of youth has all the same characteristics noted above for
bullies and victims, sharing bullies’ characteristics of low academic performance and
being negatively influenced by peers, but, similar to victims, they are also noticeably
rejected by peers. Although the group of bully-victims was not always included in the
studies, the researchers suggest that bully-victims seem to be the group most in need
of prevention and intervention programs.
In their investigation of bullying outcomes for adolescents in secondary schools in
East London, Rothon, Head, Klineberg, and Stansfeld (2011) found that although a
high level of parent support was associated with good mental health in general, high
levels of support from friends served as the protective factor against adverse academic
consequences in the wake of bullying. However, support from friends or family did
not protect victims from the mental health consequences, such as depressive symptoms
in males.
Due to the increase in bullying, there has been concentrated effort in the past 10
years not only to investigate the nature of this form of aggression, but also to develop
school-based prevention programs.
Multifinality and equifinality
Cook et al. (2010) suggest that shared characteristics of bullies, victims, and
bully-victims can be accounted for by the principle of multifinality. Recall
that multifinality refers to similar beginnings but different outcomes, while
equifinality refers to different beginnings but similar outcomes.
Cyber bullying Although having a large collection of “cyber friends” may provide
a sense of social comfort and reduce feelings of social anxiety and loneliness (Ando &
Sakamoto, 2008), there is also the potential for misuse and abuse of the internet as an
instrument of social aggression. In their recent paper on cyber aggression, Schoffstall
and Cohen (2011, p. 588) define cyber aggression as “intentional behavior aimed
at harming another person or persons through computers, cell phones, and other
electronic devices, and perceived as aversive by the victim.” The authors elaborate the
different forms that cyber aggression may take, including: “flaming (a brief heated
exchange), harassment, denigration, impersonation, outing, trickery, exclusion/
ostracism, stalking, and happy slapping (violence photographed via a camera phone)”
(Schoffstall & Cohen, 2011, p. 588). The authors make the distinction between cyber
aggression and cyber bullying, stating that while the intent of cyber aggression is to
inflict harm, this process may not include one perpetrator and victim, nor does it imply
that the behavior is necessarily repetitive. As a result, it is suggested that approximately
only one-quarter (21–25%) of cyber harassment and aggression meets the criteria for
bullying (Wolak, Mitchell, & Finkelhorn, 2007). Reports of bullying and cyber bullying continue to reach unprecedented levels. A survey of 177 grade seven students in
an urban city in Canada revealed that 54% reported being bullied in the “traditional”
sense, while over 25% reported being a victim of cyber bullying; furthermore, the
majority of youth did not report these incidents to an adult (Li, 2007).
Externalizing Problems and Disruptive Behavior Disorders
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Cyber bullying can be perceived as more dangerous and threatening than “traditional” bullying because the perpetrator can remain anonymous. Cyber bullying
has been used to threaten, embarrass, harass, and socially target and isolate victims
(Hinduja & Patchin, 2009; Williams & Guerra, 2007). More recently, studies have
focused on sexual harassment via cyber bullying, in the transmission of unsolicited
messages or photos of a sexual nature, or propositions to engage in sexual acts
(Hinduja & Patchin, 2009). Researchers have used qualitative methods such as focus
groups (Mishna, Saini, & Solomon, 2009) and mixed methods research (Guerra,
Williams, & Sadek, 2011) in an attempt to better understand the underlying dynamics from the students’ points of view. Results have revealed the increasing tendency
to use sexualized messages targeting victims in middle and secondary school (Guerra
et al., 2011; Mishna, Saini, & Solomon, 2009).
Oppositional defiant disorder
There are two major disorders of childhood associated with excess aggression; however, the way in which these disorders are classified depends on the system used. The
DSM-IV-TR specifies oppositional defiant disorder (ODD) and conduct disorder
(CD) as separate disorders with individual symptom lists, requiring three out of a
possible 15 symptoms for CD and four out of a possible eight symptoms for ODD.
Of the two disorders, ODD is the less severe disorder. On the other hand, the ICD-10
conceptualizes ODD as a subtype of CD with a 23-item symptom list consisting of
15 more severe items (similar to the CD list of the DSM) and eight less severe items
(resembling the DSM symptoms for ODD).
ODD and CD: two disorders or one?
There is on-going controversy whether ODD and CD represent a continuum,
with ODD being a milder form of CD, or if they represent two distinct disorders.
There are several arguments for retaining two distinct disorders, including age of
onset (which is much earlier for ODD than CD). Also, the vast majority of those
with ODD (75%) never develop CD and the disorders manifest qualitatively
different forms of aggression. The ICD-10 states that “many authorities consider
that ODD patterns of behavior represent a less severe type of CD rather than a
qualitatively distinct type,” although it does go on to say that “research evidence
is lacking on whether the distinction is qualitative or quantitative” (WHO, 1992,
p. 212).
Definition The age of onset for ODD is typically between four and eight years of
age, and ODD represents a persistent pattern of defiant, disobedient, provocative, and
negative behaviors. The behaviors are primarily directed towards authority figures, and
include:
r
r
loss of temper;
spitefulness and vindictiveness;
230
r
r
r
r
r
r
Clinical and Educational Child Psychology
arguments and confrontations with adults;
defiance and noncompliance;
refusal to accept blame; blaming others;
becoming irritated easily; touchiness;
deliberate annoyingness;
anger and resentfulness.
Symptoms are not better accounted for by CD, have onset within the developmental
period (prior to 18 years of age), and are in excess of what would be anticipated
given the age of the child. Clinicians are cautioned to exclude transient oppositional
behaviors which can commonly occur at different stages of development, such as
the increase in autonomous and demanding behaviors that accompany certain developmental transitions (e.g., the “terrible twos”; adolescence). Behaviors that include
violations of societal norms, rules, or the rights of others will likely fall under CD.
Developmentally, the behavior pattern must be beyond what would be anticipated,
given the child’s age. The DSM-IV-TR (APA, 2000) notes that transient oppositional behavior such as oppositional behaviors associated with increased autonomy is
common in toddlers and teens and would not be considered atypical during those
developmental periods, unless excessive.
Temper outbursts and temper dysregulation
There has been considerable controversy among professionals concerning how
to categorize children with serious behavior problems and moods that vacillate
between irritableness, grumpiness, and explosive angry outbursts. While many
have been labeled as bipolar in recent years, the DSM-V is suggesting a new category of temper dysregulation disorder with dysphoria to classify children with
this constellation of symptoms. The debate surrounding this proposed category
will be discussed further in Chapter 11 in the section on bipolar disorder.
Nature and course It was initially thought that ODD was a disorder that was specific
to childhood and that children would either outgrow the disorder or the disorder
would intensify culminating in conduct disorder. However, a more recent study by
Biederman et al. (2008) revealed that over 16% (16.6%) of those with ODD continued
to evidence symptoms at 25 years of age, while Harpold et al. (2007) found that 30%
of those with ODD and comorbid ADHD the symptoms persisted into adulthood.
This is a significant finding, because comorbidity rates for ODD and ADHD have
been reported to be as high as 65% (Biederman et al., 1996; Petty et al., 2009). Given
the high prevalence rate for this comorbid combination, it has been suggested that
comorbid ODD and ADHD might represent a specific presentation of symptoms that
is evident in some families (Petty et al., 2009). Children with earlier onset of ODD are
at greater risk (30%) for developing CD (Connor, Glatt, Lopez, Jackson, & Melloni,
2002) which is three times greater than for those who have later onset.
Our understanding of ODD has been limited in the past by research that has
tended to include both ODD and CD in the same samples of disruptive disorders,
Externalizing Problems and Disruptive Behavior Disorders
231
which has masked individual differences in the outcomes. Current research focus is
on separating the two disorders in order to obtain more information specific to these
individual disorders (Greene et al., 2002; Petty et al., 2009). Longitudinal studies
have found that youth diagnosed with ODD are at greater risk for developing major
depressive disorder than peers without the disorder (Biederman et al., 2008).
Prevalence and etiology It is estimated that between 2% and 16% of the population would meet criteria for a diagnosis of ODD. Although gender differences are
evident in childhood, with males having higher prevalence rates for ODD, by adolescence the rates equalize (APA, 2000). Although 75% of those with ODD never
develop CD, 90% of those with CD have an initial diagnosis of ODD (Rey, 1993).
Unfortunately, there is minimal information available regarding the etiology of ODD
since there are no investigations of the origin of ODD separate from those systematic investigations of “behavior disorders” which clump ODD and CD together.
The most that is known pertains to CD, which has been studied more exclusively
because of the severity of the disorder, and will be discussed in the section on conduct
disorder. Presently there is a widespread belief that ODD results from an interaction
between complex risk and protective factors, although much more is known of the risks
(AACAP, 2007).
Assessment and treatment/intervention
Assessment There are a number of different methods and instruments available
for assessing externalizing behaviors, such as ODD, which were previously discussed
at length in Chapter 5. Instruments can include a variety of behavioral rating scales
completed by parents, teachers, and the child, while methods can include such activities
as direct observations of the child in the classroom or at playtime and diagnostic
interviews.
Prevention/intervention For preschoolers, some Head Start Programs have
demonstrated positive outcomes in reducing future incarceration and delinquent
behaviors (Connor et al., 2002; Greenspan, 1992). Other parenting programs, such as
home visitation for families at high risk (Eckenrode et al., 2000), and group programs
with discussions focusing on videotaped modeling, have also had positive outcomes
(Webster-Stratton, 1994). Parent training programs seem to be the most successful for younger children with ODD, while cognitive behavioral methods seem more
appropriate for school-age children and adolescents with ODD and CD (Brestan &
Eyberg, 1998). Greene, Ablon, Goring, Fazio, and Morse (2004) have developed a
program that focuses on emotion regulation, frustration tolerance, problem solving,
and flexibility. The program, Collaborative Problem Solving (CPS), focuses on parent
education (underlying parent/child dynamics) and interventions aimed at deficits in
child information processing (cognitive distortions). Results have been very favorable. Other programs that have demonstrated success in assisting children to enhance
problem-solving skills and manage anger include Problem Solving Skills Training
(PSST: Kazdin, 1996) and Coping Power (Larson & Lochman, 2002). Coping Power
is a 33-session program based on weekly small group sessions involving cognitive
behavioral techniques (in vivo practice) designed to improve anger management.
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Clinical and Educational Child Psychology
Disorders of conduct
Definition While children with ODD exhibit a persistent form of disobedience and
defiance that typically has an onset prior to 10 years of age, youth with conduct disorder experience a more severe, repetitive, and persistent form of disordered behavior that involves a violation of the rights of others, or a serious violation of
social norms.
There are four categories of symptoms that accompany this disorder, which have
been evident within the past 12 months, with at least one symptom evident in the
past six months. According to the DSM, at least three symptoms are required for a
diagnosis, from a list of 15 potential symptoms:
Aggression to people and animals:
r bullies, threatens, or intimidates others;
r initiates fights;
r uses a weapon that can cause serious harm;
r physically cruel to others;
r cruel to animals;
r has stolen while confronting a victim (mugging, purse snatching);
r has forced someone into sexual activity.
Destruction of property:
r deliberate fire setting to cause serious damage;
r deliberately destroying others’ property.
Deceitfulness or theft:
r has broken into someone’s house, building, or car;
r lies to obtain goods or favors or to avoid obligations (“cons others”);
r has stolen items of non-trivial value (shop lifting, forgery).
Serious rule violations:
r often stays out all night, beginning before 13 years of age;
r has run away from home, staying out overnight (twice, or once if lengthy);
r often truant from school, beginning before 13 years of age.
Given the wide range of symptoms, individuals with CD can present with a heterogeneous mix of characteristics, and severity. The DSM uses the specifiers mild, moderate,
and severe to distinguish between youth who possess few symptoms and exhibit minor
tendencies to harm from those who exhibit many symptoms of the disorder and can
inflict significant harm on others.
Sub-types of CD The DSM recognizes two subtypes of CD: childhood-onset
type which refers to children who present with at least one symptom of CD prior to
10 years of age; and adolescent-onset type for youth who exhibit no symptoms prior
to 10 years of age.
The ICD lists several subtypes of CD, including:
r
unsocialized conduct disorder: behaviors occur in isolation, usually with rejection
from peer groups, and evident in such acts as bullying, fighting, and assault;
Externalizing Problems and Disruptive Behavior Disorders
r
r
233
socialized conduct disorder: behaviors occur in the context of deviant peer group
activity;
mixed disorders of conduct and emotions: this classification is used for comorbid
presentations. Youth with depressive conduct disorder would meet criteria for both
CD and depressed mood (symptom criteria for depression include loss of interest
and pleasure, misery, self-blame, hopelessness, and sleep and appetite disturbances).
Other emotional combinations are also possible (e.g., anxiety, phobias, obsessions
and compulsions, hypochondriasis, depersonalization, and so on).
Sub-types, systems, and comorbidity
Recall that a major difference between the DSM and ICD systems is that the
ICD seeks to determine a predominant diagnosis, while the DSM allows for
comorbidity for as many diagnoses that meet criteria (Kolvin & Trowell, 2002).
Due to the high rates of comorbidity of CD with emotional disorders, the ICD
has created sub-types of CD to address this issue.
Callous and unemotional traits Some youth with CD exhibit traits that have been
labeled as callous and unemotional (CU) to reflect the underlying lack of empathy
and affect that accompany this type of CD (Frick & Viding, 2009). There has been
significant research to support the identification of this cluster of traits as a unique
subtype of CD (Lynam, Caspi, Moffitt, Loeber, & Stouthamer-Loeber, 2007). As a
result, it has been suggested that the callous and unemotional specifier be used to label
a unique sub-type of CD. This subtype would require at least two of the following
criteria, with two having been demonstrated across at least two settings over the past
12 months:
r
r
r
r
lack of remorse or guilt: does not feel bad or guilty when he/she does something
wrong (except if expressing remorse when caught and/or facing punishment);
callous-lack of empathy: disregards and is unconcerned about the feelings of others;
unconcerned about performance: does not show concern about poor/problematic
performance at school, at work, or in other important activities;
shallow or deficient affect: does not express feelings or show emotions to others,
except in ways that seem shallow or superficial (e.g., his/her emotions are not
consistent with his/her actions); can turn emotions “on” or “off” quickly, or use
emotions for gain (e.g., to manipulate or intimidate others (Scheepers, Buitelaar,
& Matthys, 2011, p. 90).
Nature and course As previously mentioned, Frick et al. (1993) found that behaviors
most closely related to CD symptoms were more likely to be classified as covert rather
than overt, and contained both destructive (property violations) and nondestructive
acts (status violations). Youth with CD can exhibit a host of aggressive behaviors
towards others in open acts of aggression (physical fights) but can also commit more
covert acts of intimidation, issuing threats or gaining power through manipulation,
lying, deceit, and failure to follow through on promises or obligations (APA, 2000).
234
Clinical and Educational Child Psychology
Research has demonstrated that children exposed to poverty or stressful life events,
or who have a history of parental psychopathology (especially antisocial personality disorder), are at increased risk for developing conduct problems. Poor monitoring
and supervision, low levels of parent warmth and engagement, and harsh/inconsistent
parenting have all been associated with increased aggression and behavior problems
(Patterson, Reid, & Dishion, 1992), as has association with deviant peer groups (Fite,
Colder, Lochman, & Wells, 2007). Neighborhoods that are violent and involve antisocial activity also provide an environment that increases the risk of youth developing
CD (McCabe, Lucchini, Hough, Yeh, & Hazen, 2005).
Using an ecological and transactional model, the Conduct Problems Prevention
Research Group (CPPRG, 2011) charts the potential course of behavioral difficulties
in a child from the onset of minor conduct problems to the culmination in serious
and violent behaviors, based on the child’s interaction with forces in the immediate
or proximal environment (family, peers, neighborhood, school, teachers) as depicted
in Bronfenbrenner’s (1979) microsystem. The developmental pathway is constructed
based on our knowledge of the risk factors noted earlier. The trajectory begins with a
difficult temperament evident in problems of impulse control and behavior regulation,
within the context of a home where the parent is ill-equipped to manage the behavior,
especially if living within the stressful conditions of a disadvantaged neighborhood
with few resources, supports, or extra time. In these conditions, the research would
predict that, by the time school age arrives, the child will likely be poorly prepared
and lacking in the necessary skills to be successful academically or socially, and be
at risk for peer rejection (Dodge, Coie, & Lyman, 2006) and conflict with teachers
(Stormshak et al., 2000).
Within this type of scenario, children continue to follow the path towards CD based
on their lack of social skills and problem-solving ability, eventually disengaging from
a system that is a constant reminder of failure. Ultimately, the youth find support in
a deviant peer group who share a sense of isolation and regain their power through
aggression and violence (Dodge et al., 2006).
Lynam et al. (2007) investigated the interaction of impulsivity and neighborhood
disadvantage and found that impulsive adolescents were at increased risk for engaging
in delinquent activity, relative to peers with low impulsivity, if they lived in neighborhoods high in economic disadvantage. However, although both Lynam et al. (2007)
and the CPPRG (2011) address the biological characteristic of impulsivity, neither
of these papers addresses other biological factors that may have an impact on the
outcome. The biological side of the interaction will be addressed next.
Prevalence and etiology Both biological and environmental factors have been implicated in the development of CD. Elevated levels of the hormone testosterone have
been linked to the genetic transmission of aggressive impulses (Dabbs & Morris,
1990), while lower levels of Dopamine beta-hydroxylase (DBH), an enzyme that
converts dopamine to norepinephrine, may produce increased risk taking and sensation seeking in youth (Quay, 1986). Behavioral theorists have studied parent–child
interactions and have proposed a coercive model whereby patterns of noncompliance
and coercive responses can result in an on-going and negatively reinforced pattern of
behaviors (Patterson, Shaw, Snyder, & Yoerger, 2005). This is especially true when
the temperament of the child (high emotion reactivity) and parent (inconsistent,
impulsive) are a poor fit (Barkley, 1997).
Externalizing Problems and Disruptive Behavior Disorders
235
Some of the highest levels of comorbidity with CD are seen in ADHD, substance
abuse, and depression. Approximately half of youth diagnosed with CD will have
comorbid bipolar disorder (Kovacs & Pollock, 1995) and half will also have a substance
abuse problem (Reebye, Moretti, & Gulliver, 1995).
Assessment and treatment/intervention Youth with serious behavioral disorders have
been treated in a wide variety of settings and, depending on the degree of severity,
interventions may take place in the school setting, in alternative schools, or in residential treatment centers. Community-based programs that have been empirically
supported include: successful placements in specialized foster care (Chamberlain &
Reid, 1998): successful treatment of juvenile offenders using Multisystemic Therapy
(Schoenwald, Borduin, & Henggeler, 1998); and a five-day-a-week, in-home family
preservation program using cognitive behavioral methods (Wilmshurst, 2002).
Fast Track Prevention Intervention The CPPRG (2011) recently released the
results of their 10-year intervention program involving 891 early-starting children
(69% male; 51% African American) who were randomly assigned to intervention
or control conditions (445 intervention; 446 control) involving four geographical
locations across the United States, and 55 schools, selected on the basis of crime
and poverty statistics. The study used a multi-gating screening procedure, involving
screenings of ratings for disruptive behavior obtained from parents and teachers for
all kindergarten children attending the 55 schools across three cohorts (1991–1993).
Children who scored within the top 40% on teacher ratings were selected for homebased ratings. Intervention procedures were instituted in two phases: the elementary
school phase (grades 1–5), consisting of opportunities for parent training, home visitations, academic tutoring, and child social skills training; and the middle and early
high school phase (grades 6–10), offering a middle school transition program, groups
for parents and youth concerning adolescent topics (such as positive involvement and
monitoring), and youth forums (addressing topics such as peer pressure). Results from
the multiple-gating screening procedure predicted an 82% likelihood of exhibiting an
externalizing disorder by 18 years of age, for those children who were rated in the
top 3 percentiles, on combined parent–teacher ratings. Involvement in the long-term
prevention program reduced the risk to half of that predicted for this group. Furthermore, not only did participation in the prevention program prevent these children
from being diagnosed with CD, the positive effects continued to remain when they
were re-assessed two years after termination of the program. The authors suggest that
the program had the biggest impact on those with the most severe forms of CD,
which justifies the use of this prevention program for those at highest risk; however,
effects were limited for groups in the study demonstrating more “moderate risk.”
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10
Internalizing Problems
and Anxiety, Mood, and
Somatic Disorders
Chapter preview and learning objectives
Internalizing problems: an overview
Negative affectivity
Worries, fears, and rituals
Anxiety disorders
Specific phobias
Nature and course
Etiology and prevalence
Assessment and treatment
Separation anxiety disorder (SAD)
Nature and course
Etiology and prevalence
Treatment
General anxiety disorder (GAD) or overanxious disorder
Nature and course
Etiology and prevalence
Treatment
Obsessive compulsive disorder (OCD)
Nature and course
Etiology and prevalence
Treatment
Social phobia
Nature and course
Etiology and prevalence
Treatment
Panic attacks and panic disorder
Nature and course
Etiology and prevalence
Treatment
Mood disorders: an overview
Major depressive disorder (MDD) and dysthymia
Clinical and Educational Child Psychology, First Edition. Linda Wilmshurst.
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Nature and course
Etiology and prevalence
Assessment and treatment
Bipolar disorder (BD)
Nature and course
Etiology and prevalence
Treatment
Suicide and suicide prevention
Somatic complaints and problems
Nature and course
Etiology and prevalence
Assessment and treatment
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Chapter preview and learning objectives
Children and adolescents can express a wide range of emotional responses to distressing circumstances that can be transitory, and appropriate to their developmental
level, or represent reactions that are more intense, severe, persistent, and beyond
what would be normally anticipated. The objectives of this chapter include enhanced
understanding of:
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internalizing problems evident in children and adolescents who respond to distressing circumstances by avoidance and overly controlled emotions. Responses
often include worries, fears, phobias, anxieties, fluctuations in mood, or somatic
complaints;
the continuum in severity for any of the above difficulties, based on the intensity,
severity, and duration of the problem, given developmental expectations;
similarities and differences in criteria for determining whether problems are considered to be within the abnormal range and thereby considered to be disorders
of childhood and adolescence, and how these disorders are conceptualized by the
two different systems of classification.
There are several different types of anxiety disorder that can present with a wide variety
of symptoms, including: specific phobias, separation anxiety disorder, generalized
anxiety disorder, obsessive compulsive disorder, social phobia, and panic disorder
(with or without agoraphobia). Although post-traumatic stress disorder (PTSD) and
acute stress disorder have been listed in the category of anxiety disorders in the DSM,
it is likely that these disorders will be reclassified under the category of stress disorders
in the future, and for our purposes will be discussed under trauma in Chapter 13.
Internalizing problems: an overview
Internalizing problems result from behaviors that are “overcontrolled.” Achenbach
and Rescorla (2001, p. 93) describe internalizing behaviors as “problems within the
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self, such as anxiety, depression, and somatic complaints,” without known medical
cause, which result in withdrawal from social contact.
What are the internalizing problems?
Anxiety disorders (anxious and inhibited responses), mood disorders (both
unipolar depression and bipolar depression), and the somatoform disorders
(emotional distress manifesting as physical discomfort) all share symptoms that
are internally oriented.
Negative affectivity
Anxiety and depression often occur together in young children with a comorbidity
rate as high as 60–70%. Developmentally, anxiety is a precursor to depression (Kovacs
& Devlin, 1998); however, in young children, symptoms of generalized anxiety and
depression often occur together as anxious-depressed symptoms before they become
more differentiated (Ebesutani, Smith, Bernstein, & Chorpita, et al., 2011). Ebesutani
et al. (2011, p. 679) describe negative affectivity as “a broad temperamental factor of
emotional distress that is related to mood states such as sadness, fear, guilt, and anger,”
as opposed to positive affectivity which refers to a mood state that reflects a sense
of enthusiasm. The concept of negative affectivity is derived from the tripartite model
(Watson, Clark, & Carey, 1988) developed to explain the similarities and differences
between anxiety and depression. Within this model, depression is recognized as a
unique state of low positive affect (anhedonia); however, depression shares the state
of negative affectivity with anxiety (Chorpita, 2002; Chorpita, Plummer, & Moffit,
2000).
The Anxious/Depressed scale of the Achenbach System of Empirically Based
Behaviors (ASEBA) is a scale that measures negative affectivity, while the Withdrawn/Depressed Scale is a measure of low positive affect (Achenbach & Rescorla,
1996). It has been suggested that temperament may influence a child’s responses to
novel or challenging situations, in such a way that some children are predisposed to
respond to challenging situations with high levels of negative affectivity evident in
displays of anger, frustration, fear, irritability, or sadness (Putnam, Ellis, & Rothbart,
2001). High levels of negative affectivity have been associated with problems in selfregulation, poor social competence, and both externalizing and internalizing problems
(Calkins, 2002). Although a child’s temperament was once thought to be a relatively
stable factor during early development (Buss & Plomin, 1984), it is now recognized
that as children mature and face new challenges in different contexts and settings
(such as transitions to school), their temperaments may change as they incorporate
new self-regulatory behaviors into their repertoire. For example, Blandon, Calkins,
Keane, and O’Brien (2008) reported that increases in young children’s self-regulatory
behaviors were accompanied by decreases in negative affectivity. Furthermore, Blandon et al. (2008) found that parenting practices could serve to moderate behavior in
children who demonstrated higher biological reactivity. If the parent was warm and
responsive, children exhibited a decline in negative emotions; however, if the parent
was overly controlling and paid minimal attention to the child’s goals and behaviors,
children responded with increased negative affectivity.
Internalizing Problems and Anxiety, Mood, and Somatic Disorders
Table 10.1
245
Common fears experienced at different developmental levels
Developmental stage
Common fears
Toddler stage (1–2 years)
Preschool (3–6 years)
Early school (6–10 years)
Strangers, toileting activities, personal injury
Imaginary creatures, monsters, the dark, animals
Small animals, the dark, environmental factors such as lightning
and thunder, threats to personal safety
Source: Adapted from Barrios and Hartmann (1977).
Worries, fears, and rituals
The majority of children experience a wide variety of fears at various developmental
levels. The most common fears for children at the preschool and primary level are
presented in Table 10.1.
In their study of developmental trends in fears, worries, and ritualistic behaviors,
Laing, Fernyhough, Turner, and Freeston (2009) distinguish between children’s fears,
“a concern regarding danger or threat to survival,” and worries, “concern regarding
possible social or cognitive discomfort” (p. 352). Fears and worries both tend to peak
around seven years of age. However, while fears tend to dissipate after this age, the
prevalence of worries increases dramatically, with 80% of children admitting to worrying after seven years of age (Muris, Merckelbach, Gadet, & Moulaert, 2000). Fears
evolve from an earlier focus on imaginary creatures to more realistic concerns related
to physical danger/bodily injury and ultimately to feared social or medical situations
(Ollendick, Yule, & Ollier, 1991). Although common worries can be experienced by
most children and adolescents at some stage (potential harm of a loved one, school
performance, social groups), as children get older, there is more emphasis on worrying
about performance issues and social evaluation (Laing et al., 2009). Girls report more
fears (Ollendick et al., 1991) than boys at all ages, and also report more worries overall
(Ollendick, 2001).
Engaging in ritualistic and repetitive behaviors is common in childhood, particularly between the ages of two and seven (Evans et al., 1997; Leonard, Goldberger, &
Rapoport, 1990; Zohar & Felz, 2001). The most common rituals include: perfectionism (having to be “just right”), ordering and arranging objects in precise, prescribed
ways; hoarding; and concerns about dirt (Evans et al., 1997; Leonard et al., 1990),
or rituals embedded in common activities such as eating or bedtime routines (such as
insisting that a parent read the same book over and over in a particular manner).
Why perform rituals?
Rituals can increase feelings of security and reduce anxious feelings related to
fears about contamination, injury, and strangers (Evans, Gray, & Leckman,
1999).
Developmentally, preschoolers tend to dwell on a sense of “sameness,” repetition,
and constancy, while older children are more likely to demonstrate rigid adherence
to complex rules that define games, or engage in behaviors intended to “undo”
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potential negative consequences (Laing et al., 2009). Although it has been suggested
that ritualistic behaviors may initially (at four to seven years of age) fill an adaptive
function by providing a sense of personal control, rituals may become increasingly
maladaptive after this time. Laing et al. (2009) suggest that since worry and obsessions involve similar negative and potentially uncontrollable and intrusive thoughts,
ritualistic behaviors may become increasingly associated with relieving tension and
anxiety, setting the stage for the later development of obsessive compulsive disorder
(OCD) which will be discussed later in this chapter.
Anxiety disorders
There are eight anxiety disorders currently listed in the DSM (APA, 2000), although
two of the disorders (post-traumatic stress disorder and acute stress disorder) will most
likely be reclassified under stress disorders in the future. For the purposes of this book,
the anxiety disorders will be introduced according to developmental onset (earlier to
later onset disorders), while the stress disorders will be covered in the final chapter
on trauma. The eight anxiety disorders include: specific phobias, separation anxiety
disorder, general anxiety disorder, obsessive compulsive disorder, social phobia, and
panic disorder.
Specific phobias
A specific phobia is a persistent unreasonable fear of specific events or objects causing extreme anxiety (lasting at least six months). Although adolescents and adults
recognize that the fear is unreasonable, children may not. Given the distress caused,
there is a persistent tendency to avoid the feared object/situation.
Nature and course The most common specific phobias include: natural type (e.g.,
heights, storms), animal type, blood-injection type, situational type (e.g., elevators,
bridges, enclosed spaces), and other specific fears (e.g., fear of clowns). Fear of animals
is a common form of phobia with childhood onset, while one of the most common
sources of phobias in middle childhood (nine to 13 years) is a fear of spiders (Muris,
Merckelbach, Meesters, & Van Lier, 1997).
Etiology and prevalence Phobias develop and are maintained by a combination of
biological factors (genetics, temperament), behavioral factors (modeling, operant or
classical conditioning), cognitive factors and situational factors (e.g., fear of all dogs
after being bitten, parenting practices). The prevalence rate for specific phobias in
children is approximately 5%; however, they may be evident in 15% of children who
are referred for other anxiety-related issues (Ollendick, King, & Muris, 2002).
Assessment and treatment Behavior rating scales, as discussed in Chapter 5, can be
helpful in providing information about general symptoms of anxiety in children and
adolescence. Semistructured interviews, such as the Anxiety Disorders Interview Schedule for the DSM-IV: Child and Parent Versions (ADIS for DSM-IV; Silverman &
Albano, 1996; Silverman, Saavedra, & Pina, 2001), and affective scales, such as the
Revised Manifest Anxiety Scale-2 (RCMAS-2; Reynolds & Richmond, 2008) can be
particularly helpful in the identification of anxious children.
Exposure treatments such as participant modeling and reinforced practice are
two well-established treatments for phobic disorders in children (Ollendick & King,
Internalizing Problems and Anxiety, Mood, and Somatic Disorders
247
1998). Adults or peers can serve as models and the procedure can take place in
reality (in vivo), through media (e.g., video viewing) or by imagination, allowing
the opportunity for children to experience positive and non-fearful reactions through
observational learning. In vivo participation is the most successful of these methods.
Phobias and classical conditioning
In Chapter 2, we discussed how Little Albert was conditioned to fear a rat. The
classical conditioning paradigm can be used to explain how Sally acquires her
fear of flying, through a strong negative emotional association:
Flying (neutral stimulus) → means of travel (neutral response)
Turbulent flight (unconditioned stimulus) → fear (unconditioned response)
Flying (conditioned stimulus) → fear (conditioned response)
Sally is now fearful of flying which may even generalize to all airborne activities,
such as parasailing and balloon riding, through stimulus generalization.
One important exposure technique, systematic desensitization (Wolpe, 1958)
is based on principles of successive approximation, as an individual is gradually
exposed to the feared object, while in a relaxed state. Desensitization requires three
important steps:
1. development of a fear hierarchy (steps from the least to most feared aspect of
the phobia);
2. training in deep relaxation;
3. pairing the feared object/event with deep relaxation at each step, until the fear is
eventually mastered.
Using the previous example of fear of flying, the therapist would construct a fear
hierarchy (lowest to highest fear associated with flying) based on Sally’s subjective
units of distress (SUDs). The program might begin with reading travel brochures,
packing to go away, driving to the airport, and picking up the ticket. At each step, Sally
would be instructed to do her relaxation exercises, until that step no longer elicited an
anxious response. Ultimately, the final step would be to board the plane and take off.
Fear and emotive imagery
Lazarus and Abramowitz (1962) developed a systematic desensitization program for children substituting emotive imagery for relaxation training. The
researchers had children face their fears by creating stories whereby their favorite
hero conquered the fear. In this case, child mastery became the antidote
for fear.
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Table 10.2
Clinical and Educational Child Psychology
Symptoms of separation anxiety disorder (SAD)
Separation anxiety disorder (SAD): intense worries about separation from the caregiver,
evident in at least three of the following:
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Unrealistic, persistent worry about the caregiver succumbing to accident or harm, or not
returning
Preoccupation and worry that some future event (being lost, kidnapped) will result in
separation from the caregiver
Persistent reluctance to attend school or school refusal
Reluctance to sleep alone, without caregiver
Reluctance or refusal to sleep away from home
Inappropriate fear of being alone without the caregiver
Repeated nightmares about separation
Persistent physical complaints (such as nausea, stomachache, headache)
If time is of the essence, then an exposure treatment called flooding is a possibility.
Sally would immediately accompany the model on board the airplane, face her fear,
and realize that all flights are not turbulent.
Separation anxiety disorder (SAD)
Children with SAD experience intense worries about separation from the caregiver,
and are often consumed with fears of harm befalling a caregiver, which underlies the
need to stay close to the caregiver.
Nature and course Symptoms of SAD are very similar in both classification systems,
with the exception that the ICD suggests onset prior to six years of age, compared to
onset prior to 18 years in the DSM. Both systems require symptoms to be present for
at least four weeks.
Children with SAD experience intense worries about separation from the caregiver
evident in at least three symptoms presented in Table 10.2. It is not uncommon for
children to become physically ill or to experience panic attacks when forced to leave
the caregiver.
School refusal
The most common symptom of SAD is school refusal. However, while 75%
of those with SAD refuse to attend school, only one-third of all children who
demonstrate school refusal have SAD (Black, 1995). Other causes of school
refusal include fear (bullying and victimization) or reluctance to return after a
legitimate absence (illness).
Etiology and prevalence The exact cause of SAD is unknown, although it has
been suggested that temperament (inhibited/wary) and attachment patterns (insecure/anxious) interact in the wake of threats of separation to evoke habitual stress
Internalizing Problems and Anxiety, Mood, and Somatic Disorders
249
responses (Ollendick, 1998). Parent overprotectiveness may reinforce a child’s
avoidant behaviors and increase a child’s dependency on the caregiver (Hudson
& Rapee, 2000). Approximately 4% of children and adolescents experience SAD,
although among clinical populations the prevalence rate is more than double that
(10%) of the population at large (APA, 2000). Once diagnosed with the disorder,
children may re-experience symptoms if faced with stressful situations in the future,
such as school transitions.
Treatment Cognitive behavioral therapy (CBT) has been successful in treating SAD,
general anxiety disorder (GAD), and social phobia (see Ollendick & King, 1998,
for a review). The Coping Cat Program has been successful for a wide range of
ages (seven to 16 years) and can be adapted for individuals (Kendall, 1994; Kendall
& Southam-Gerow, 1996) or groups (Flannery-Schroeder & Kendall, 2000). Two
shorter versions, Coping Koala and Coping Bear, have also been successful in the
treatment of SAD, GAD, and social phobia, for individuals (Barrett, 1998) and groups
(Muris, Meesters, & van Melick, 2002).
Coping Cat Program
The program consists of 16 to 18 sessions with approximately half of the sessions
devoted to developing coping skills and the remainder to applying the skills in
vivo and imagined conditions. The key stages in the process are represented by
the FEAR acronym:
F Feel frightened (physical symptom recognition).
E Expect the worse (awareness of negative mental set).
A Attitude/Actions can help (practice positive coping statements).
R Results and Rewards (monitor, evaluate, and self-reward).
General anxiety disorder (GAD) or overanxious disorder
GAD is a condition of excessive worry and anxiety, where the individual is unable to
control the worry, even if he or she is aware that the worry is unreasonable.
Nature and course Both classification systems present a similar clinical picture for
GAD with minor variations: the ICD requires evidence of three symptoms, while
the DSM requires three symptoms for adults but only one symptom for children. In
addition, the ICD requires that multiple symptoms must prevail across at least two
situations. While the DSM acknowledges that worries about performance may be
pervasive across academic and other activities, such as sports, this is not a requirement
for diagnosis.
Symptoms are consistent with “free-floating anxiety” and may include: excessive
need for reassurance, marked tension (problems concentrating, sleeping, irritability),
recurrent somatic complaints, or excessive concerns regarding performance, physical
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health, or other potential negative outcomes. The DSM cautions about over-diagnosis
of children with GAD because many of the symptoms overlap with other disorders
(e.g., ADHD, PTSD, mood disorders).
Etiology and prevalence There is high heritability for GAD; if one twin has the
disorder, there is a 30–40% likelihood the other twin will also have the disorder (Eley,
1999). The neurotransmitter GABA (gamma-aminobutyric acid) is responsible for
sending a message to inhibit excitability and anxiety levels; however, a malfunction (too
little GABA, or too few receptors) causes the anxiety loop to continue to fire (Lloyd,
Fletcher, & Minuchin, 1992). From a cognitive behavioral perspective, heightened
perceptions of threat drive an avoidant coping style which is negatively reinforced
by reduced anxiety (Lengua & Long, 2002). Parents who are overprotective and
anxious can actually exacerbate the problem by encouraging avoidant behaviors in
their children (Dadds, Barrett, Rapee, & Ryan, 1996). Lifetime prevalence rate for
GAD is between 2% and 5%, with likely child onset between eight and 10 years of age
(Last, Perrin, Hersen, & Kazdin, 1992). Females are twice as likely to be diagnosed
with GAD (APA, 2000).
Anxiety and attachment
Children who demonstrate anxious attachment patterns as infants are twice as
likely to develop an anxiety disorder compared to peers who are securely attached
(Warren, Huston, Egeland, & Sroufe, 2005).
Treatment The Coping Cat Program discussed earlier (for SAD) is also appropriate
for GAD. Although CBT can be successful for children with GAD, researchers have
found that if the parents are also anxious, unless parents are simultaneously enrolled
in a parent anxiety management program, the children do not benefit from CBT
(Cobham, Dadds, & Spence, 1998).
Obsessive compulsive disorder (OCD)
The essential features of obsessive compulsive disorder (OCD) are recurrent and
intrusive obsessions (thoughts) and/or persistent ritualistic compulsions (behaviors).
Both systems of classification require the disorder to cause significant distress, and the
recognition that the obsessions or compulsions are unreasonable, although the DSM
suggests that children may not be aware that the obsessions and compulsions are
unreasonable. Conceptually the two classification systems differ regarding symptom
duration. While the ICD requires that symptoms exist for two consecutive weeks, the
DSM focuses on the length of time engaged in the OCD rituals on a daily basis (e.g.,
more than an hour a day).
Nature and course In children and youth, obsessions (irrational thoughts) and compulsions (stereotypical and uncontrollable behaviors) often represent a number of
Internalizing Problems and Anxiety, Mood, and Somatic Disorders
Table 10.3
251
Common obsessions and compulsions in children and youth
Obsession
Compulsion
Contamination
Safety
Orderliness/symmetry
Repetitive rituals
Hoarding
List making
Hand washing, excessive cleaning, showering, teeth brushing
Checking doors, windows, locks, appliances (turned off)
Aligning, arranging
Counting, tapping, touching, repetitive phrases
Collecting useless items (rubber bands, paper clips)
Making lists, checking lists
recurring themes and preoccupations, the most common of which are presented in
Table 10.3.
Although ritualistic behaviors are common and peak in the preschool years (two to
four years of age), children with OCD demonstrate a pattern of increasing rituals and
compulsions in middle and secondary school (Zohar & Bruno, 1997). In the youngest
children, compulsive rituals are often not accompanied by obsessional thoughts (Geller
et al., 1998).
In their study of 70 children and youth with OCD, Swedo, Rapoport, Leonard,
Leanane, and Cheslow (1989) found that 85% engaged in compulsive hand washing
resulting from fears of contamination, while almost half (46%) demonstrated checking
rituals. Aggressive and violent images, including thoughts of self-harm, were evident
in almost one-third (30–38%) of youth in another study, while somatic obsessions
were evident in 38% of youth (Riddle et al., 1990). Rituals may go undetected if
performed in secrecy and students may be misdiagnosed as “slow” due to problems
completing work resulting from competing rituals (repeating words to themselves,
tapping and counting, or the need to be perfect). They may also feel the need to hide
their secret from family and peers (Wever & Phillips, 1994).
Etiology and prevalence Biological, behavioral, cognitive, and parenting models have
all suggested possible etiologies for OCD. Genetically, the risk for OCD is higher
in first degree relatives with OCD or Tourette’s disorder, and onset of OCD in
childhood is associated with having a tic disorder, being male, and having multiple
OCD symptoms (Tucker, Leckman, & Scahill, 1996). Since antidepressants (SSRIs)
have been successful in treating cases of OCD, low levels of the neurotransmitter
serotonin have been linked to the disorder. The orbital region of the frontal cortex
and the caudate nuclei (in basal ganglia) are involved in turning thoughts into actions;
specifically, the caudate nuclei is responsible for filtering primitive impulses (aggressive
thoughts and images) prior to sending the messages to the thalamus. In individuals
with OCD, PET scans have detected overactivity in these regions of the brain (Saxena,
Brody, & Maidment, 1999).
Streptococcal infection and OCD
PANDAS “is an acronym for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infection. As defined, the criteria include
prepubertal children with either a tic or obsessive-compulsive disorder in
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whom a Group A beta-hemolytic streptococcal infection (GABHS) triggers the
abrupt onset or exacerbation of tics/obsessive-compulsive behaviors” (Singer &
Loiselle, 2003, p. 31). Murphy and Pichichero (2002) monitored 12 youth who
developed abrupt onset of OCD or tic disorder after acquiring PANDAS. Murphy and Pichichero (2002) reported that severe OCD symptoms (hand washing
and fear of contamination) disappeared when the throat infection was treated
with antibiotics, but re-occurred in half the youth when the throat infection
relapsed. However, re-introduction of the antibiotic caused OCD symptoms to
disappear.
From a behavioral perspective, theorists have speculated that compulsions can be
serendipitously reinforced, causing the behavior to be repeated (I am nervous and wash
my hands, which relieves my anxiety, then I am more likely to repeat this behavior). Familybased models have investigated the influence of communication patterns, especially
expressed emotion (EE), on the development of OCD. Valleni-Basile et al. (1995)
found that 82% of youth with OCD had families that were high in EE (overly involved
and high levels of criticism). Cooper (1996) investigated the impact of having a child
with OCD on the family and found that over half the families (60%) complained of
detrimental effects on marital harmony, siblings, and feelings of manipulation (youth
often engage family members in the rituals). The cognitive behavioral model focuses
on the role of maladaptive thinking in OCD behaviors and suggests that it is the
detrimental combination of both feeling unable to control the thoughts or impulses
and the need to engage in the repetitive behaviors (undoing) that is at the core of the
disorder (Rachman, 1993).
Prevalence rates for OCD are between 2% and 4% of children and youth, with male
onset at 6 to 15 years, earlier than for females at 20 to 29 years (Martini, 1995).
Treatment Selective serotonin reuptake inhibitors (SSRIs) have been effective in the
treatment of OCD in children and adolescents (McClellan & Werry, 2003). Although
the tricyclic clomipramine is highly effective, adverse side effects suggest the medication should only be used in severe cases that do not respond to SSRIs (Geller, Biederman, & Stewart, 2003). Rachman’s (1993) approach to the treatment of OCD,
exposure and response prevention (ERP), uses behavioral principles of exposure to
the anxiety provoking situation (e.g., dirty floor) and then blocking the compulsive
response (cleaning). Repeated exposures, in the presence of blocked responses, take
place in a gradual systematic way. ERP has been proven to be as successful as medication in reducing OCD symptoms in children and youth (March, Frances, Carpenter,
& Kahn, 1997). Barrett, Healy-Farrell, and March (2004) investigated a family-based
cognitive behavioral treatment (CBFT), called the Focus Program (Freedom from
Obsessions and Compulsions Using Special tools), a 14-week program using principles of CBT and ERP, and engaging youth and family members in the treatment.
The program is designed to increase awareness of the disorder, and has a builtin relapse prevention component. Results revealed clinically significant reduction in
OCD symptoms.
Internalizing Problems and Anxiety, Mood, and Somatic Disorders
253
Social phobia
Social phobia as an unreasonable and persistent fear of scrutiny by others, or fear of
extreme embarrassment in social situations, resulting in an avoidance of situations that
may produce a panic attack if confronted.
Social anxiety disorder of childhood
In addition to social phobia, the ICD also recognizes social anxiety disorder
of childhood which has onset prior to age six and is a persistent or recurrent
fear and/or avoidance of strangers which may occur with adults, peers, or both,
in the presence of normal selective attachment. There is no equivalent category
for this disorder in the DSM.
Nature and course Social phobia must be present for six months for a diagnosis.
Symptoms of the disorder in children must occur in peer settings as well as adult
settings, and exposure may result in crying, tantrums, or freezing; children may not
recognize the fear as unreasonable (APA, 2000). It is not surprising to find that onset
is common in adolescence, as worries of social evaluation increase (Muris, Luermans,
Merckelbach, & Mayer, 2000). Social phobias can relate to a generalized fear of
embarrassment and humiliation in social situations (generalized social phobia) or can
be more situation-specific, such as: fear of eating, writing, or speaking in public (APA,
2000).
Etiology and prevalence The behavioral inhibition system (BIS), the brain system
that alerts individuals to potential threat, has been linked to increased anxiety and
avoidant responses, especially in children with OCD (Biederman et al., 1993; Gray,
1991). An inhibited temperament (wariness), behavioral inhibition (shy demeanor),
and a tendency to approach new situations with avoidance and distress have all been
implicated, and increased rates of social phobia have been found among children that
are behaviorally inhibited (Biederman et al., 1993).
Although the lifetime prevalence for social phobia is between 3% and 13%, onset
in childhood has been considered rare with only approximately 1–2% prevalence.
However, among children with a history of GAD or SAD, more than one-quarter
(27%) of those with GAD and 5% of those with SAD will also develop a social phobia
(Bernstein & Borchardt, 1991).
Is selective mutism an early precursor to social phobia?
Based on your understanding of social phobia, do you think that selective
mutism, which was discussed in Chapter 8, could be an early version of social
phobia?
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Clinical and Educational Child Psychology
Treatment Techniques that are helpful for specific phobias (exposure therapies, such
as systematic desensitization) can also be successfully applied to social phobias. Inclusion of a social skills training component can also be valuable to increase confidence
in social groups (LeCroy, 1994).
Panic attacks and panic disorder
Individuals with panic attacks experience an intense and overwhelming set of somatic,
emotional, and cognitive symptoms. Although the attacks last approximately 10 minutes, a severe attack can resemble a heart attack.
Nature and course The clinical features of panic attacks (panic episodes) are similar
for the DSM and ICD, although the DSM requires a specified number of symptoms
(four) to meet criteria:
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palpitations;
sweating;
trembling;
shortness of breath;
chest pain;
feelings of smothering, dying;
dizziness;
a strong urge to escape;
feelings of loss of control;
fear of going crazy;
sense of depersonalization.
Individuals who experience panic attacks often develop a panic disorder, which is a
fear of having panic attacks. Individuals who develop a panic disorder may try to avoid
going into public places (shops, crowds, buses, trains), especially alone, which places
them at risk for developing panic disorder with agoraphobia, which may literally
result in the individual becoming housebound.
Agoraphobia
The word “agoraphobia” is Greek for “fear of the marketplace” and is used to
describe a fear that can accompany panic disorder.
The DSM does not recognize agoraphobia as a disorder in its own right, but uses
the term as a specifier for panic disorder. However, the ICD recognizes agoraphobia
as a disorder in and of itself and is diagnosed when anxiety is restricted to “at least
two of the following situations: crowds, public places, travelling away from home,
and travelling alone” and involves avoidance of the phobic situation (WHO, 1992,
p. 113).
Internalizing Problems and Anxiety, Mood, and Somatic Disorders
255
Etiology and prevalence Youth who experience early onset panic disorder (prior to the
age of 20) are 20 times more likely to have a first degree relative with the disorder. The
locus ceruleus, rich in the neurotransmitter norepinephrine, has been linked to the
onset of panic attacks, sending messages to the amygdale, responsible for triggering
emotional responsiveness (Redmond, 1981). Cognitive theorists have suggested that
panic attacks can be caused by tendencies to overact and misinterpret bodily signals
(Gray, 1995).
Lifetime prevalence for panic disorder is 3.5% with the most likely onset from late
teens to early 30s. Females are twice as likely as males to suffer from the disorder
(APA, 2000).
Treatment Antidepressant medications (SSRIs) can be successful in restoring norepinephrine to normal levels (Renaud, Birmaher, Wassick, & Bridge, 1999). However,
if panic disorder is accompanied by agoraphobia, exposure techniques are also recommended.
The Panic Control Treatment for Adolescents (PCT-A; Hoffman & Mattis,
2000) has been successful in teaching adolescents awareness about the disorder and
methods that can be used to reduce panic symptoms. The program uses cognitive
behavioral techniques to correct faulty thought patterns, alleviate fear and anxiety,
and increase feelings of self-efficacy.
Mood disorders: an overview
Although Bleuler initially wrote of childhood depression in 1934, and Spitz (1946)
described anaclitic depression in infants in institutional care, many adhered to the
psychodynamic belief that young children could not experience depression, since they
lacked a well-defined ego. The term “depression” can be used to refer to a symptom,
syndrome, or disorder (Angold, 1988).
Depressed mood The transitory state of irritability and upset that a child experiences
in response to a life adjustment (adjustment disorder with depressed mood) or
disappointment are examples of a depressed mood. Children may become clingy or
sulk, while others may act out aggressively. The nature of symptoms will reflect the
circumstances and the child’s developmental level.
Depressed syndrome The ASEBA scales include two examples of depressed syndrome: anxious/depressed syndrome (characterized by a combination of negative emotions) and depressed/withdrawn syndrome (characterized by low positive affect and
social withdrawal).
Depressive disorders Mood disorders are classified according to the duration, severity, and nature of symptoms. Unipolar depression can exist in a chronic but milder
form of dysthymia, requiring fewer symptoms, but longer duration (at least two years
in adults, and one year in children), or an acute but more serious form of major
depressive disorder, a severe depressive episode lasting at least two weeks. Bipolar
disorder contains both episodes of depression (sadness) and mania (elation).
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The discussion will begin with unipolar depression (major depressive disorder and
dysthymia) and then consider bipolar disorder.
Major depressive disorder (MDD) and dysthymia
Major depressive disorder (MDD) Individuals diagnosed with MDD meet criteria
for a major depressive episode, which includes a pervasive depressed mood or loss of
interest in pleasure, lasting at least two weeks, accompanied by five of a possible nine
symptoms:
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significant weight loss/gain (children fail to meet weight/height ratios);
insomnia;
feelings of worthlessness/self-blame;
problems concentrating;
suicidal ideation;
agitation or retardation;
fatigue/loss of energy.
Depending on the number of symptoms, individuals may be diagnosed with mild,
moderate, or severe forms of the disorder. Depressed mood can appear as irritable
mood in children who may also fail to meet normal height/weight expectations
(APA, 2000).
Depression and symptom clusters
Symptoms can also be divided into categories based on similar features: vegetative symptoms (appetite/sleep disturbance), cognitive/affective symptoms (worthlessness and guilt, concentration problems, suicidal ideation), and
behavioral/psychomotor symptoms (agitation or retardation, fatigue/loss of
energy).
Dysthymia: recurrent depression Children (and teens) who evidence depressed
mood (irritability) for a period of one year may be diagnosed with dysthymia, although
for adults, the disorder must exist over a two-year period without an absence of
symptoms for more than a two-month period. Individuals with dysthymia do not
meet criteria for a major depressive episode, and a diagnosis requires at least two
symptoms from the list of symptoms for major depressive episode.
Nature and course
Toddlers and preschool children Luby et al. (2002, 2004, 2006) have isolated
two forms of depression in preschoolers: hedonic depression (reactive depression)
and anhedonic depression (loss of pleasure or joy associated with melancholia).
Anhedonic depression, the more severe variant, includes: a genetic predisposition
(family history of depression), more neurovegetative symptoms, and higher elevations
Internalizing Problems and Anxiety, Mood, and Somatic Disorders
257
of cortisol. Those with the hedonic form are more influenced by situational variables,
such as poverty and living in a stressful environment.
Other depressive characteristics in preschoolers include: delay or regression in milestones, nightmares or night terrors, agitated expressions such as head-banging and
rocking (Luby et al., 2004), and disorganized play (Mol Lous, de Wit, De Bruyn, &
Riuksen-Walraven, 2002).
Primary school-age children Contrary to findings by Luby et al., traditionally,
research has found that the majority of children develop depression in response to
environmental situations, with genetic factors playing a greater role in adolescent
depression (Eley, Deater-Deckard, Fombonne, & Fulker, 1998; Thapar, Harold, &
McGuffin, 1998).
Middle childhood to adolescence Youth who suffer from depression may do so for
a wide variety of reasons, including many of the stressors that were discussed in Chapter
6. Symptoms may also be difficult to distinguish from “adolescent moodiness,” but
may be evident in:
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vague somatic complaints (headaches, body aches);
school absenteeism, poor school performance;
over-sensitivity to criticism;
reckless behavior, increased risk taking;
loss of interest in social contact, withdrawal;
complaints of boredom;
irritable outbursts;
easily upset, tearful;
talk of running away;
substance use or abuse;
repeated comments that no one cares;
difficulty in relationships. (NIMH Fact Sheet on Depression, 2011)
Etiology and prevalence Significantly more research has focused on adult depression
than depression in adolescents, and even fewer studies have investigated depression in
childhood. Biological models have found low levels of the neurotransmitters serotonin
and norepinephrine in adult cases of depression, and evidence of a neuroendocrine
imbalance (hormone cortisol) in adults and recently preschoolers with depression
(Luby et al., 2002).
Cognitive behavioral models have suggested that negative thinking (a bias to
interpret events negatively; Beck, 1997) and learned helplessness (giving up in the
face of repeated failures; Seligman, 1975) were root causes of depression due to
maladaptive thinking. For Beck, thought patterns that emphasize the negative and
minimize the positive produce a feedback loop called the negative triad, which results
in feelings of hopelessness, helplessness, and worthlessness. Today, attribution theory
has expanded Seligman’s theory, integrating the nature of global (versus specific),
stable (versus inconsistent), and internal (versus external) factors into the model. For
example, if I interpret a negative event as global (having far-reaching consequences),
stable (always happening), and internal (my fault), then I am far worse off than had I
interpreted it as specific, inconsistent, and external.
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Clinical and Educational Child Psychology
Attribution theory and the stress generation hypothesis
Attribution theory can be applied to the stress-generation hypothesis (Hammen,
2006) discussed in Chapter 6. Stressful interpersonal events that are interpreted
as global, stable and internal can set the stage for the perpetuation of stressful
environmental conditions.
As has been discussed previously, family influences and parenting practices can be
supportive to youth in distress. However, an adversarial family climate (high stress/low
support) can increase the risk for depression. Sheeber, Hops, and Davis (2001) suggest that there is increased risk for depression in adolescents if the family negatively
reinforces the depression (through attention and negative thinking) or provides little
direction for enhancing emotion regulation.
Cicchetti and Toth (1998) developed an ecological transaction model to explain
how skills and adaptations acquired or not acquired over the course of development
can increase the risk or provide protection against the development of depressive
disorders later on. For instance, a mother’s ability to soothe an infant in distress can
be instrumental in the maturation of brain networks to inhibit negative arousal levels
and assist in the development of self-regulation in the child. Children who are unable
to self-soothe can be in a perpetual state of distress.
Interpersonal problems that cause increased risk for developing depression include:
family conflict, parenting style, and rejection by peers. Child temperament has also
been implicated as a moderating factor. Children with positive emotionality tend to
engage in more social activity and are much less prone to depression than their peers
who demonstrate negative emotionality (fearfulness, irritability) and less positive
social contact (Rothbart & Bates, 1998). Children with depression may evidence low
frustration tolerance, vacillate between anger and sadness, and evidence poor academic
and social outcomes (Yorbik, Birmaher, Axelson, Williamson, & Ryan, 2004).
The prevalence of depression more than doubles from childhood (2%) to adolescence (4–7%) (Costello et al., 2002). Higher rates of the melancholic subtype
(anhedonic) are evident in adolescent populations. Characteristics of depression in
adolescence most likely also include psychomotor retardation (hypersomnia, e.g.,
over-sleeping) and delusions (auditory hallucinations). In adolescence, there are significant tendencies for depression to be a comorbid feature of several other disorders,
including: behavior disorders, ADHD, anxiety disorders, substance disorders, and eating disorders (APA, 2000). Although rates for depression are similar for younger boys
and girls, by 16 years of age twice as many females suffer from depression than males
(Hankin & Abramson, 2001).
Assessment and treatment
Assessment Behavioral rating scales discussed in Chapter 5 can provide a general
sense of whether a child’s or adolescent’s level of depression is outside normal expectations. Affect rating scales, such as the Beck Youth Inventories (Beck, Beck, & Jolly,
Internalizing Problems and Anxiety, Mood, and Somatic Disorders
259
2005), include a specific scale for student self-ratings for depression (thoughts related
to self, life, and future expectations).
Treatment Medication has been far less successful in the treatment of depression
in children. Currently, in the United States, only fluoxetine (Prozac) is approved for
use with children eight years of age and older, although other medications have been
prescribed on an off-label basis. Close monitoring is required, since the medication
can worsen the depression and pose a suicide risk. Most of the successful treatment
programs involve CBT, which may not be developmentally appropriate for very young
children. Commonly used therapeutic techniques for very young children involve
art therapy and play therapy, although empirical support is often lacking for these
programs.
Medical management of depression in children and youth has been highly controversial for several reasons. Approximately 30–40% of children fail to improve and
many antidepressants (Prozac, Zoloft, Paxil) carry high risks for increased depression
and suicide attempts (Emslie et al., 1997). However, after an extensive review of
pediatric medication trials, Bridge et al. (2007) suggest that the benefits of antidepressant medications far outweigh the risks. CBT is the most frequent treatment
for depression in adolescents (67%), with youth-focused treatment far more common
than family-focused treatment (Weisz, Doss, & Hawley, 2005). Specific programs that
have achieved success include a cognitive behavioral treatment program developed by
Lewinsohn, Clarke, Rhode, Hops, and Seeley (1996), and a 12-week interpersonal
therapy program for adolescents developed by Mufson, Dorta, Moreau, and Weissman
(2005).
Bipolar disorder (BD)
While unipolar depression is associated with low positive affect (anhedonia), bipolar
depression involves both a depressed mood and an elated mood of which there are
three versions: mania, hypomania, or mixed episodes. The following discussion
will focus on cases of bipolar disorder that evidence moods of mania (Bipolar I) or
hypomania (Bipolar II).
Nature and course Individuals with BD vacillate between moods of depression and
elation. Manic episodes are less enduring than depressive episodes, with episodes often
triggered by some stressful event. Manic episodes last for at least one week, and include
an elevated, expansive mood, likely to include a number of the following symptoms
(at least three, according to the DSM):
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inflated self-esteem/grandiosity;
pressured speech;
decreased need for sleep;
distractibility/poor attention;
flight of ideas;
increased goal-directed and motor activity;
engagement in high-risk behaviors (sexual, financial).
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Clinical and Educational Child Psychology
Full manic episode
80
70
60
Average range
50
40
30
Major depressive
episode
20
T scores
(a)
80
70
Hypomanic
episode
60
50
Average range
40
30
20
Major depressive
episode
10
T scores
(b)
Figure 10.1 (a) Bipolar I. (b) Bipolar II.
Variations and types of BD Severity of BD is related to the nature of the manic
episode. Bipolar I meets criteria for a major depressive episode (MDE) and a manic
episode, resulting in marked impairment in functioning, while Bipolar II meets criteria for MDE and a hypomanic episode (elevated mood, lasting for at least four
days, accompanied by three symptoms of less severe impact), without causing marked
dysfunction.
A third type of disorder that has both depressed and elated moods is cyclothymic
disorder, a chronic condition (like dysthymia), lasting for years and vacillating between
periods of hypomania and depression which does not meet criteria for MDE. Adults
who experience four cycles within one year are considered to be rapid cycling. Bipolar
with mania and hypomania are displayed in Figure 10.1.
Issues in the diagnosis of BD in young children BD is a chronic psychiatric disorder that is highly heritable. Until recently, BD was thought to have its earliest onset
in late adolescence or only to exist in adults (Loranger & Levine, 1979). Recent
Internalizing Problems and Anxiety, Mood, and Somatic Disorders
261
investigations suggest that cases of adult BD have prepubertal onset (Geller, Zimerman, Williams, Bolhofner, & Craney, 2001).
BD in adolescence In their research on BD, Masi et al. (2006, p. 682) asked two
very important questions:
1. Is BD in childhood the same clinical disorder in adolescence?
2. Are there variations in symptom presentation at these developmental levels?
Research suggests that although the disorder remains stable across the lifespan (Biederman et al., 2005), the symptom presentation manifests differently across the lifespan.
Characteristics which distinguish adolescent onset from childhood onset include the
following:
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Adolescent onset is marked by more frequent displays of elated moods/euphoria.
Adolescents can appear irritable in a manic state and demonstrate chronic mixed
mania episodes.
Adolescents with BD also meet criteria for depression, ADHD, disruptive behavior
disorders, psychosis, and anxiety disorders.
Adolescents with BD are more equally distributed by gender.
Adolescent moods are more chronic than episodic compared to adults (Masi et al.,
2006).
Adolescent onset is associated with higher risk for separation anxiety disorder and
obsessive compulsive disorder (Lewinsohn, Klein, & Seeley, 2000).
Adolescents with BD are at greater risk for substance use disorders, as well as drug
and alcohol use (Wilens et al., 2007).
Adolescent onset BD is associated with significant deterioration in function, academically (especially mathematics), and in interpersonal relationships.
Stress, BD, and adolescence
An increase in stressors (family, romantic relationships, peers) can cause increased
mood deterioration in adolescents with BD (Kim, Miklowitz, Biukians, &
Mullen, 2007). Although 85% of adolescents with unipolar depression graduate from secondary school on time, only 58% with BD graduate on schedule
(Kutcher, 2005).
Etiology and prevalence According to the biological model, BD is a highly heritable
condition; if one parent has the disorder there is a 30–40% risk of a diagnosis in
offspring (Levine, 1999). Low levels of serotonin and high levels of norepinephrine
have been linked to BD (Shastry, 2005), as have low glutamate levels in adults and
children (Goff et al., 2002). The antipsychotic drug, risperidone, has met with some
success in treating BD in children. Amygdale (emotional processing center) volume
irregularities have been found in adults and adolescents with BD but not in children
with BD (Chang et al., 2005). Executive functioning is also impaired in youth with
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the disorder, including sustained attention, working memory, and processing speed
(Doyle et al., 2005).
When is the likely onset for BD?
In an investigation of the continuity between adult and pediatric BD, Chang
et al. (2005) report that 50% of adults indicate onset prior to 19 years of age,
while 15–28% report onset before 13 years of age. Earlier onset is associated
with the most severe, chronic, forms of BD with higher rates of comorbidity
(Perlis et al., 2004).
Internationally, prevalence rates for adult BD are similar; however, “there is considerable transatlantic debate and European skepticism over the high prevalence of
pediatric BD in the United States” (Soutullo et al., 2005, p. 498). In the United
Kingdom, not a single case of pre-adolescent mania was reported in either a large
epidemiological study (Taylor, Dopfner, & Sergeant, 2004) or a clinical sample of
2500 children (10 years of age or younger), who were seen at a psychiatric facility
in Manchester over a 10-year period (Meltzer, Gatward, Goodman, & Ford, 2000).
However, in the United States, rates of BD in children have been escalating. Brotman
et al. (2007) compared discharge rates for children, adolescents, and adults from a
psychiatric facility between 1996 and 2004. Although BD was the least frequent diagnosis for children in 1996, by 2004 BD had become the most common diagnosis,
with a 53.2% increase in children and a 58.5% increase in adolescents, compared to a
3.5% increase in adults. Possible reasons for the increase were suggested as increased
practitioner sensitivity to the disorder in children and adolescents, or “rebranding’
children and youth with BD who had previously been diagnosed with other disorders.
Why is it so difficult to diagnose BD in children?
Diagnosis of BD in children is difficult for many reasons, including shared
symptoms with ADHD (38.7%) and oppositional defiant disorder (35.9%), and
symptoms of a chronic irritable subtype that differs from symptoms of BD in
adolescence or adulthood (Masi et al., 2006).
Childhood onset is significantly more prevalent in males and manic symptoms can
be evident at five years of age or younger (Biederman et al., 2005). A predominant
feature of childhood BD is a severe form of irritability often associated with aggressive
and out-of-control behavior (Wozniak et al., 1995). Geller et al. (2001) found that
85% of their sample with BD (with an average age of seven years) had rapid cycling,
often evident in rapid mood shifts on a daily basis. Wilens et al. (2003) modified the
symptoms of the DSM to better suit diagnostic impressions for preschool and primary
school-age children. The adapted symptom list is available in Table 10.4.
Internalizing Problems and Anxiety, Mood, and Somatic Disorders
263
Table 10.4 Wilens et al.’s modified DSM-IV-TR criteria for BD in preschool and primary
school-age children
“Mania: A severely impairing episode, lasting for a week or longer”, with elevated symptoms
of “giddy, goofy, drunk-like” or “severely irritable mood with frequent temper tantrums,”
including at least three of the following symptoms:
r
r
r
r
r
r
r
Grandiosity (feeling superior, trying to complete tasks well beyond ability level)
Insomnia
Pressured speech (may be unintelligible)
Flight of ideas (resulting in confusion)
Increased distractibility
Extreme goal-oriented behavior (high risk, perseverative behaviors)
Engaging in excessive pleasurable activities (e.g., masturbation)
Source: Wilens et al. (2003, p. 497).
Treatment Medical management of the disorder is the first line of defense. In addition to risperidone, lithium (a mood stabilizer) has also been successful in treating
BD in children. However, unpleasant side effects from lithium (stomach upset, nausea, weight gain) often can result in poor compliance with a medical regime (Tueth,
Murphy, & Evans, 1998), and high relapse rates (90%) for those who do not comply
(Strober, Morrell, Lampert, & Burroughs, 1990). The American Academy of Child
and Adolescent Psychiatry (AACAP, 2007) recommends a multimodal treatment plan
combining medical management and psychotherapeutic interventions.
Diagnosis and medical management
Youth with BD who are given an antidepressant without a mood stabilizer may
produce a manic state. Misdiagnosis of BD as ADHD and subsequent placement
on stimulant medication can cause excessive manic symptoms and high levels of
aggression (NIMH Fact Sheet: Child and Adolescent Bipolar Disorder, n.d.).
Suicide and suicide prevention
In a global study of suicide rates among adolescents from 90 countries (aged 15 to
19 years), suicide accounted for 9.1% of all deaths (7.4 per 100,000) with more than
twice the rate in males (10.5 per 100,000) than females (4.1 per 100,000), placing
suicide as the fourth leading cause of death in young males, and the third leading
cause of death in young females (Wasserman, Cheng, & Jiang, 2005). A study of
suicide patterns among Finnish youth found that shooting was the most common
method of suicide and, while adult suicides were most prevalent in the spring, youth
suicides peaked in autumn, corresponding with the start of the school year (Lahti
et al., 2006). Currently, suicide rates in the United States and Canada are among the
highest in the industrialized world (Johnson, Krug, & Potter, 2000).
Although suicide is rare in childhood, rates become increasingly common after 14
years of age. Approximately 2000 teens commit suicide annually in the United States,
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Clinical and Educational Child Psychology
although as many as 500,000 are estimated to make unsuccessful suicide attempts
(Goldman & Beardslee, 1999). Youth with depressive disorders account for one-third
to one-half of all suicide attempts (Beautrais, 1998).
Not all suicidal thoughts (suicidal ideation) will result in a suicide attempt or completed suicide. However, warning signs of a potential suicide attempt may include:
r
r
r
r
r
r
oversensitivity to criticism;
preoccupation with death (drawings, stories);
social withdrawal, loneliness, self-criticism;
running away;
temper tantrums;
low frustration tolerance. (Papolos, Hennen, & Cockerham, 2005)
Risks for suicide High levels of neuroticism, novelty seeking, and low self-esteem
have all been associated with increased risk for suicide, as has a family history of a
suicide attempt (Fergusson, Beautrais, & Horwood, 2003). Association with deviant
peers increases the risk for suicide, possibly due to accompanying alcohol abuse (Brent,
2001). The three factors most strongly related to completed suicides are a previous suicide attempt, substance/alcohol abuse, and having a mood disorder. Suicide attempts
most often are precipitated by a stressful incident, including: teen pregnancy, physical
or sexual abuse, trouble with school or the law, family discord, exposure to suicide
(contagion effect), and a recent relocation (Shaffer et al., 1996). Dave and Rashaad
(2009) found that body dissatisfaction (perception of being overweight) in adolescent
girls increased the risk of suicidal ideation by 6%, and suicide attempts by 3.6%.
Protective factors Absence of a family history of suicide (Fergusson et al., 2003),
family cohesion, and family connectedness (Borowsky, Ireland, & Resnick, 2001) are
protective factors in the home. Having a cohesive support group of peers reduces the
risk for girls, while sharing activities with friends reduces the risk for boys (Bearman
& Moody, 2004).
Etiology Having a relative who was suicidal increases the risk for suicide over 30%
(Gould, Shaffer, & Davies, 1990). Low serotonin levels can increase the risk for
another suicide attempt tenfold (Roy, Rylander, & Sarchiapone, 1997). There is
speculation that aggressive males have lower serotonin levels which makes them more
likely to act on suicidal impulses (Mann, Brent, & Arango, 2001).
Treatment and prevention Treatment for depressed mood often involves some
combination of CBT and medication. School-based suicide screening and prevention
programs are common, but most have met with disappointing results and possibly
even iatrogenic effects (when treatments harm). For example, in one study, students who were most in need reported feeling even more distressed and hopeless after
participating in the program (Overholser, Hemstreet, Spirito, & Vyse, 1989). One
very successful program that has empirically demonstrated a 40% reduction in suicide attempts is the Signs of Suicide (SOS) Prevention Program (Aseltine, 2003;
Aseltine & DiMartino, 2004; Aseltine, James, Schilling, & Glanovsky, 2007). As of
2004–2005, the program had been launched in 675 schools across the United States.
The program focuses on treating suicidal ideation as a medical emergency, and trains
Internalizing Problems and Anxiety, Mood, and Somatic Disorders
265
secondary school students to recognize the warning signs and provide an immediate
response (ACT: Acknowledge the suicide signs of others and take them seriously; let them
know you Care, and you want to tell; and Tell a responsible adult). SOS is a comprehensive curriculum-based program that instructs students in recognizing suicidal
ideation and provides an opportunity to complete a self-administered screening device
(currently the program uses the Brief Screen for Adolescent Depression (BSAD); Lucas
et al., 2001) to indicate whether they score above a level that indicates the need for
immediate help. Part of the curriculum is delivered through a short film called Friends
for Life to assist in the recognition of and response to suicidal ideation in peers.
Somatic complaints and problems
Adults with somatoform disorders express mental distress through physical symptoms, in the absence of any organic cause. There are two major types: hysterical
disorders (accompanied by actual loss or change of physical function) or preoccupation disorders (excessive concern regarding physical well-being or status). However,
adult symptom criteria are often difficult to apply to children due to the nature of the
symptoms required. A descriptive summary of hysterical and preoccupation disorders
is presented in Table 10.5.
Table 10.5
Somatoform disorders
Hysterical disorders
Actual loss or change in physical functioning
Somatization disorder
Pain disorder
Long-standing, recurring, and causing significant distress and
impaired functioning:
Pattern of multiple somatic complaints located in four different
bodily regions (e.g., head, back, joints, stomach, chest, etc.);
Evidence of at least eight different pain symptoms, including:
gastrointestinal (2 symptoms)
sexual (1 symptom)
pseudoneurological (1 symptom, e.g., paralysis, conversion
symptoms, problems swallowing, amnesia, fainting, etc.)
One or more physical complaints (fatigue, loss of appetite,
gastrointestinal problems, etc.) that endure for at least six
months, are without medical cause, and cause significant
distress and impaired functioning
Loss of function (motor or sensory, e.g., hand paralysis, issues
swallowing, blindness, deafness, problems with balance) without
medical basis; criteria state that a psychosocial stressor or
psychological factor must be linked to the onset of the disorder
Significant pain in the absence of medical reasons
Preoccupation disorders
Excessive concern about physical status or well-being
Hypochondriasis
Preoccupation with the belief that one has a serious disease,
causing significant distress and dysfunction
Preoccupation with an imagined or exaggerated defect in physical
appearance, causing significant distress and dysfunction
Undifferentiated
somatization disorder
Conversion disorder
Body dysmorphic disorder
266
Clinical and Educational Child Psychology
The diagnostic criteria for somatization disorder preclude a diagnosis in childhood, since one of the symptoms is pain related to sexual function. As a result some
studies have used undifferentiated somatization disorder as an alternative. Conversion disorder is one of the most researched somatoform disorders due to its dramatic
nature, and disabling symptoms, such as paralysis, blindness, or seizures, without
any organic basis. Pain disorder, especially recurrent abdominal pain (RAP), is
a high incidence disorder that can be a chronic and long-term condition. Little is
known about hypochondriasis and body dysmorphic disorder (BDD) in pediatric
populations, although BDD often has onset in adolescence. Since, there is limited
information about these disorders in children and adolescents, the following discussion will briefly describe how children and adolescents manifest internalizing problems
through physical and somatic complaints.
Nature and course There is relatively little documentation of developmental trends in
somatic complaints despite the fact that at least one study found that 20% of children
who visit physicians with somatic complaints have no verifiable cause (Robinson,
Greene, & Walker, 1988), while another revealed that health services use peaked
for children during times of increased stress and school transitions (Schor, 1986).
Headaches (25%), low energy (21%), sore muscles (21%), and abdominal pain or
discomfort (17%) are the four commonest symptom complaints, with younger children
reporting a predominant symptom (headache, stomachache), and older children citing
multiple symptoms, including: pain in the extremities, muscle aches, and neurological
symptoms (Garber, Walker, & Seman, 1991; Walker, Garber, & Greene, 1993).
Etiology and prevalence
Somatization disorder Although symptom requirements for somatization disorder
often preclude a diagnosis in children, using the criteria for undifferentiated somatization disorder, Essau, Conradt, and Petermann (2000) sampled 1035 German
adolescents (aged 12 to 17), and found that two-thirds met criteria for undifferentiated somatoform disorder. In this study, the most commonly reported symptoms
were headaches (15.5%), a lump in the throat (14.4%), and abdominal pain (12.4%).
Females reported more symptoms than males (Garber et al., 1991) and 10–20% of
females with the disorder have a close relative with the disorder (APA, 2000).
Conversion disorder Conversion disorder is rarely diagnosed in children under 10
years of age, and more likely to be diagnosed in later childhood or early adulthood. In
childhood, the most likely symptoms are seizures and loss of balance (APA, 2000), with
a 10-year study in Australia reporting that 69% of children presented with abnormal
gait (Grattan-Smith, Fairley, & Procopis, 1988). It is not uncommon for preschool
children to develop pseudoparesis or a limp, lasting hours or days, following a minor
injury (Fritz, Fritsch, & Hagino, 1997). In their study of 194 Australian children with
conversion disorder, Kozlowska et al. (2007) found that 55% presented with multiple
conversion symptoms, the most common of which included: disturbances of motor
function (64%) and sensory function (24%), pseudoseizure (23%), and respiratory
problems (14%). High rates of comorbidity were found with anxiety, depression, and
symptoms of fatigue and pain.
Internalizing Problems and Anxiety, Mood, and Somatic Disorders
267
Little is known about the etiology of the disorder; however, some studies suggest
that symptoms are related to errors in emotional information processing (Kozlowska,
2005), while maintenance of a conversion disorder might result from the reinforcement the condition receives. At least one study has found that 90% of children who
developed conversion disorder had experienced a significant stressor at home or at
school prior to developing the disorder (Siegel & Barthel, 1986), while a more recent
study by Kozlowska et al. (2007) emphasizes the need to consider more commonplace
stressors for children such as family conflict or loss/separation from attachment figures.
Pain disorder The most common form of pain disorder among young children is
recurrent abdominal pain (RAP). Between 10% and 30% of young children (Garber,
Walker, & Seman, 1991) presenting with symptoms of (RAP) report that the pain
occurs three or more times within a three-month period, causing significant distress,
but without any organic physical basis.
Children who report RAP at four years of age have a threefold risk of reoccurrence
six years later (Borge, Nordhagen, Botten, & Bakketeig, 1994).
Body dysmorphic disorder (BDD) In adolescence, negative body image and body
dissatisfaction can have a significant impact on feelings of self-worth (Rudiger, Cash,
Roehrig, & Thompson, 2007) and can place teenagers at increased risk for depression,
anxiety, and disorders related to body image, such as eating disorders and BDD
(Greenberg et al., 2010; Phillips, 2005). It is not surprising to find that onset of
BDD often occurs in adolescence (Phillips et al., 2005). Youth with BDD are severely
distressed and impaired by imagined flaws that distort their self-view, causing them to
spend excessive time (more than one hour, and often three to eight hours) in front
of a mirror checking or grooming defects, the most common of which relate to skin
(acne, scarring, blotches), hair, or stomach (Phillips et al., 2006). Time devoted to
dwelling on their imperfections can cause significant dysfunction in other parts of their
lives (homework, schoolwork, peer relationships) and places them at risk for increased
isolation (Hadley, Greenberg, & Hollander, 2002).
Assessment and treatment There are few assessment instruments that address somatic
complaints. However, two of the most popular are the Somatic Complaints syndrome
scale (ASEBA; Achenbach & Rescorla, 2001), and the Somatic Concerns scale of the
Personality Inventory for Youth (PIY; Lachar & Gruber, 1995).
Limited information is available about the causes and treatment of somatoform
disorders in young children, although approximately 90% of onsets are associated with
significant stressors in the home or school (Fritz, Fritsch, & Hagino, 1997). Initially,
children are likely to be seen by the medical profession and may go undiagnosed for
a lengthy period of time.
At least one study has demonstrated success with adolescents using a cognitive
behavioral program and SSRIs for the treatment of BDD (Albertini, Phillips, &
Guevremont, 1996), while a more recent case study reported clinically significant
improvement (77.8% reduction in symptoms of BDD) after 12 individual sessions of
CBT, with parent involvement, over an eight-week period. Several different techniques
were involved in the program, including: reframing maladaptive and self-defeating
thought patterns, development of a reward program with parent involvement, and
exposure and response prevention (Greenberg et al., 2010).
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11
Later Onset Problems: Eating
Disorders and Substance
Use/Abuse
Chapter preview and learning objectives
Eating disorders: an introduction
Anorexia nervosa (AN)
Nature and course
Bulimia nervosa (BN)
Nature and course
AN and BN: a comparative look
Issues in classification: a developmental perspective
Prevalence of eating disorders
Etiology, treatment, and prevention of eating disorders
Etiology of eating disorders
Treatment for AN
Treatment for BN
Prevention of eating disorders
Substance use and abuse
Nature and course
Issues in classification: a developmental perspective
Adolescent substance use: an international perspective
Overall trends in drug usage
Alcohol
Tobacco
Cannabis (marijuana)
Inhalants
Gateway drugs
Vulnerability and risk for drug use
Etiology, treatment, and prevention of substance use/abuse
Etiology
Treatment programs
Prevention programs
References
Clinical and Educational Child Psychology, First Edition. Linda Wilmshurst.
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Chapter preview and learning objectives
There is increasing concern, worldwide, regarding adolescents who in the midst of
significant physical, cognitive, emotional, and social changes are at increased risk
for developing eating disorders and substance use/abuse problems. In this chapter,
discussion will focus on issues and concerns about the appropriateness of the ICD
and DSM criteria for these disorders in children and youth, and the challenges that
prevention programs face in trying to reduce the onset of these problems.
In this chapter, readers will gain an increased understanding of:
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the similarities and differences between anorexia nervosa (AN) and bulimia nervosa
(BN), and binge eating disorder (BED);
developmental features of the eating disorders and probable causes as to why the
disorders occur;
treatment options for eating disorders and the status of prevention program development;
worldwide trends in youth substance use over the past 15 years;
prevalence rates for four of the most commonly used substances: alcohol, tobacco,
cannabis, and inhalants;
gateway drugs;
treatment challenges, and programs for substance use in youth;
global prevention programs aimed at resistance to initiation of drug use and reducing drug use.
Eating disorders: an introduction
Body dissatisfaction can develop in youth who try to measure up to the thin ideal
portrayed in the media, placing them at increased risk for developing eating disorders,
the third leading cause of chronic illness among young women 15 to 19 years of age
(Rosen, 2003). In this chapter, the question addressed is: When does disordered eating
become an eating disorder? The ICD and the DSM recognize two important eating disorder syndromes that share a preoccupation with body weight or shape (morbid fear of
fatness) and deliberate attempts to control and sustain weight loss: anorexia nervosa
(AN) and bulimia nervosa (BN). Approximately 80 to 90% of those with eating disorders engage in self-induced vomiting, while one-third misuse laxatives (APA, 2000).
In addition to the main eating disorder categories, the classification systems also recognize atypical eating disorders. In the category of eating disorders not otherwise
specified (EDNOS), the DSM includes such atypical variants as binge eating disorder
(BED), which refers to out of control eating, or binge eating, consuming an excessive
amount of food without the compensatory behaviors found in bulimia nervosa.
Anorexia nervosa (AN)
Nature and course The two classification systems are in agreement that a diagnosis
of AN must include a body weight maintained at less than 85% of that expected, or
Quetelet’s body-mass index (BMI) of 17.5 or less (the ICD recommends using BMI
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for individuals aged 16 years or over). In prepubertal patients, failure to meet expected
gain during growth may be evident.
Weight (lb) × 703
BMI = Height2 (in2 )
Weight (kg)
BMI = Height2 (m2 )
BMI is defined as the individual’s body weight divided by the square of his or her
height. Although the ranges may vary by country, the normal range is approximately
18.5 to 25. A score of 25+ is considered to be overweight, while a score below 18.5
is considered to be underweight.
In addition, several other criteria are required for a diagnosis of AN. Symptoms are
very similar in both classification systems, although the ICD focuses more on physical
side effects (problems of metabolism, endocrine system, electrolyte imbalance), while
the DSM focuses more on the behavioral patterns and the identification of subtypes
within the disorder. Other criteria include:
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intense fear of gaining weight or becoming fat;
body image distortion/disturbance in perception of body weight;
endocrine system malfunction, loss of menstrual cycles in females (amenorrhea),
or loss in sexual interest/potency in males.
In addition to the above criteria, the DSM specifies two types of AN: the restricting
type (which has an absence of binge-eating or purging), and the binge eating/purging
type (engaging in binge eating followed by purging behaviors (self-induced vomiting,
misuse of laxatives or diuretics).
According to the DSM, the restricting subtype is evident in approximately half of
those diagnosed with AN who maintain their low weight through restraint and selfdeprivation. Fasting and excess exercise may characterize this subtype. Those with the
binge eating/purging subtype engage in acts to purge the body of calories associated
with food intake, on a regular (weekly) basis. Herzog et al. (1999) found that individuals with the binge eating/purging subtype had less overall life satisfaction and poorer
scores on global functioning than those with the restricting subtype. The restricting
subtype can become trapped in an anorexic cycle which is displayed in Figure 11.1.
The categories of atypical anorexia nervosa (ICD) and EDNOS (DSM) can be
used to classify individuals who have all the symptoms to a mild degree, or who
are missing some of the key features of AN (e.g., they do not meet the criteria for
significant weight loss, or amenorrhea is absent). Individuals with AN can develop
physiological side effects resulting from chronic starvation and weight loss which can
place them at risk for succumbing to severe dehydration and electrolyte imbalance
that could result in hospitalization. One out of 10 with AN who are hospitalized will
die, either from physical complications or suicide (APA, 2000, p. 588).
Although the disorder is primarily associated with adolescent girls and young
women, it is also possible to diagnose the disorder in adolescent boys, young men,
children approaching puberty, and older women. While it was once thought that the
typical onset for AN was 14 to 18 years of age, studies are showing evidence of eating
Later Onset Problems: Eating Disorders and Substance Use/Abuse
Fear of
obesity
279
Anxiety
Dieting and
selfstarvation
Distorted
body
image
Obsession
with food
Figure 11.1 Anorexic cycle.
disorders (ED) at younger and younger ages (six to 12 years of age), with more boys
having ED than previously thought, and in trends that are recognized internationally
(Cumella, 2005; Favaro, Caregaro, Tenconi, Bosell, & Santonastaso, 2009; Pinhas,
Morris, Crosby, & Katzman, 2011). Until recently, the disorder was primarily seen in
Western and developed, industrialized societies (APA, 2000).
Where in the world?
AN is found most frequently in the United States, Canada, Europe, Australia,
Japan, New Zealand, and South Africa. Prevalence rates drop significantly in
countries where women have less say in the decision-making process (Miller &
Pumariega, 1999).
Developmental features Symptoms may appear different in young adolescents compared to adults. Typical behaviors may include: the wearing of baggy clothes to hide
thin physique, self-induced vomiting, food restriction, avoiding eating with others,
preoccupation with food or food preparation, and low self-esteem. Children may
restrict fluids as well as solids, resulting in serious medical outcomes (Nicholls, 2005).
Onset prior to puberty has been associated with more disordered eating habits, greater
need for social desirability, and higher scores on measures of internal locus of control
(Arnow, Sanders, & Steiner, 1999).
Who is in control?
Rotter’s (1966) locus of control (LOC) theory suggests that individuals can
take responsibility for their own actions (internal locus of control) or place
control in the hands of others; for example, luck or fate (external locus of
control). It is not surprising to find that adolescents with AN score higher on
internal LOC.
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Clinical and Educational Child Psychology
Fear of
obesity
Anxiety
Diet and
thoughts
of food
Purge
Guilt
Binge
Figure 11.2 Bulimia nervosa: the binge–purge cycle.
Bulimia nervosa (BN)
Nature and course Although BN and AN share common features, BN is typically
characterized by repeated patterns of bingeing (overindulgence and overeating) followed by guilt-induced purging patterns (vomiting, laxatives). Criteria for BN are
similar in both the DSM and the ICD, and include:
r
r
persistent preoccupation with eating, and succumbing to overeating, consuming
large quantities of food in an concentrated period of time;
overeating followed by compensatory behavior, such as self-induced vomiting,
drugs (appetite suppressants, diuretics).
However, while the ICD does not specifically state any duration or frequency criteria,
the DSM is more stringent, stating specific times related to the duration of overeating
(e.g., two hours) and the frequency with which binge-purge episodes occur (twice
weekly, for at least three months). In addition the DSM also includes two specifiers
for BN: a purging type of BN (where individuals engage in immediate compensatory
behaviors to remove food from the system, such as self-induced vomiting, enemas,
laxatives, or diuretics) and a non-purging type of BN (where individuals engage in
other forms of compensatory behaviors, such as excess exercise or fasting).
Repeated self-induced vomiting can cause excess stomach acids that deteriorate
the esophagus and teeth enamel. Vomiting can actually increase appetite, leading to
another binge–purge episode (Wooley & Wooley, 1985). As is evident in Figure 11.2,
the binge–purge cycle is a self-perpetuating and self-defeating practice of guilt and
shame for overeating, resulting in purging to remove the food.
Strategies to avoid detection can include: eating in several different restaurants over
the course of a binge; buying food in different locations; and hiding in a private
location (bedroom) to indulge in privacy. As might be anticipated, these activities
only serve to increase emotional discomfort, self-loathing, and shame.
Later Onset Problems: Eating Disorders and Substance Use/Abuse
281
Developmental features Impulsivity and loss of control can increase the risk for
alcohol and drug use/abuse. High school students with BN are at increased risk for
substance use, sexual activity, suicide attempts, and theft (Conason & Sher, 2006).
Piran and Robinson (2006) suggest that individuals with BN may be drawn to illicit
drugs such as stimulants and cocaine, since these drugs suppress appetite and increased
metabolism, both of which could enhance weight loss. Symptoms of bingeing, purging, and dieting in middle school and secondary school have been linked to marijuana
use, tobacco use, and alcohol consumption (Field et al., 2002). Johnson, Cohen,
Kasen, & Brook, (2002) found that adolescents with BN are at higher risk for major
depression and substance abuse, while Stice, Burton, and Shaw (2004) found a bidirectional relationship between BN and depression, such that each disorder carried an
increased risk for the other disorder.
AN and BN: a comparative look
AN and BN share a morbid fear of obesity, a distorted perception of body shape and
weight, and preoccupation with thinness and food. In addition, both can have onset
after an intense period of dieting. The main distinction between these two disorders
is weight: individuals with AN maintain a body weight less than 85% of the ideal;
individuals with BN have fluctuating weight loss/gain. When features of the classic
restricting type of AN are viewed in relation to features of the classic purging type of
BN, differences are evident in several areas (see Table 11.1).
Personality differences are also evident in different eating disorder types. For example, those with AN tend to be more withdrawn and perfectionist, and can be obsessional in their thinking. Comorbidity with obsessive compulsive disorder has been
noted for individuals with AN (Anderluh, Tchanturia, & Rabe-Hesketh, 2003). Individuals with BN can engage in more risk-taking behavior and tend to come from
families that are more negative, emotive, and chaotic.
Issues in classification: a developmental perspective Appropriateness of the current
diagnostic criteria for eating disorders in children and youth is the subject of debate
(Bryant-Waugh & Lask, 1995; Nicholls, Chater, & Lask, 2000). In a sample of
81 children aged seven to 16 years, Nicholls et al. (2000) compared the reliability
of diagnostic criteria for eating disorders for the ICD, DSM, and the Great Ormond
Street classification system which was developed specifically for children (GOS; BryantWaugh & Lask, 1995; Lask & Bryant-Waugh, 2000). Inter-rater reliability was lowest
for ICD (likely due to the large number of categories) and substantial for DSM,
with the exception of the EDNOS category which was broad enough to apply to
over half their sample (51.2%). The highest inter-rater reliability was for the GOS,
which the authors attribute to appropriateness of the criteria for child populations and
the inclusion of “characteristics that must be absent for the diagnosis to be made”
(Nicholls et al., 2000, p. 322), which greatly assisted diagnostic decision making.
The GOS identifies five eating disorders: anorexia nervosa, bulimia nervosa, food
avoidance emotional disorder, selective eating, and pervasive refusal (See Table 11.2
for criteria).
Based on the GOS categories, 26% of children were diagnosed with “food avoidance
with emotional disorder” while 13.7% were diagnosed with “selective eating” (13.7%).
Differential diagnoses using the three classification systems for AN were 28% (ICD),
282
Table 11.1
Clinical and Educational Child Psychology
A comparison of characteristics of AN and BN
Anorexia nervosa: restricting type
Bulimia nervosa: purging type
r
r
r
r
r
r
r
r
r
Onset 14 to 18 years
Menstrual cycles cease (three months)
Refusal to maintain body weight within
85% of average
Greater severity of medical complications,
including:
Low body temperature; low blood
pressure
Reduced bone density
Slow heart rate
Metabolic and electrolyte imbalance
Dry skin, hair loss
Lanugo (fine down-like covering on face,
extremities, and trunk)
More obsessive qualities
Families tend to be enmeshed, rigid,
overprotective, deny conflict
Personality withdrawn, rigid, perfectionist,
and obsessive
r
r
Onset 15 to 21 years
Menstrual cycles may be irregular but
do not cease
Fluctuation in body weight, low to
high
Less medical complications and risk,
with the following possible
complications:
Esophagus and teeth damage
Chronic diarrhea (laxative misuse)
Potassium deficiencies
Kidney disease
r
r
r
More sexually experienced, more
concerned about pleasing others and
having relationships
Families have more psychopathology,
expressed emotion, hostility, and
confrontation
Personality impulsive, loss of control,
outgoing and social
Sources: DSM-IV-TR (APA, 2000); Birmingham & Beumont (2004); Halmi (2002); Striegel-Moore,
Silberstein, & Rodin (1993).
32.1% (DSM), and 49.6% (GOS); for BN, the respective rates were 4% (ICD), 2.5%
(DSM), and 4.1% (GOS).
Recently, in the wake of revisions to the DSM and ICD, and research evidence of
increased prevalence rates and decreased ages of onset for eating disorders, there has
been a resurgence in advocacy for revising current criteria “to characterize developmentally sensitive alterations in symptom expression seen in children and adolescents”
(Bravender et al., 2010, p. 81).
Bravender et al. (2010) suggest several flaws in the current criteria which are not
conducive to child applications, because they do not recognize developmental limitations that compromise their suitability for children, including: cognitive criteria
inherent in concepts of endorsing a fear of fatness, risk appraisal of weight loss, and
relating self-concept to body image; physical criteria, such as amenorrhea which is not
applicable to prepubertal girls or males; and weight lost criteria which are not appropriate developmentally, since wide variability exists in individual growth patterns in children. Instead, the authors recommend that for children behavioral indicators should
replace “cognitive” criteria, that a parent should assist in providing symptom descriptions, and that in the case of bulimia and binge episodes, the threshold of symptom
frequency and duration should be lowered to one “out of control” eating episode
in three months. Finally, Bravender et al. (2010, p. 86) suggest that loss of control
eating can be operationalized for children under 12 years of age by the use of such
Later Onset Problems: Eating Disorders and Substance Use/Abuse
Table 11.2
283
The Great Ormond Street (GOS) criteria for eating disorders in children
Eating disorder
Anorexia nervosa
Bulimia nervosa
Food avoidance emotional
disorder
Selective eating
Pervasive refusal syndrome
Functional dysphagia
Criteria
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
r
Determined weight loss
Abnormal cognitions regarding weight/shape
Morbid preoccupation with weight/shape
Recurrent binges and purges
Sense of lack of control
Morbid preoccupation with weight/ shape
Food avoidance (not related to primary affective disorder)
Weight loss
Mood disturbance (not meeting criteria for affective
disorder)
No abnormal cognitions (weight/shape)
No morbid preoccupation (weight/shape)
No organic brain disease (psychosis)
Narrow range of foods (for at least two years)
Unwillingness to try new foods
No abnormal cognitions (weight/shape)
No fear of choking/vomiting
Weight can vary (low, normal, high)
Profound refusal to eat, drink, walk, talk
Resistance to assistance
Food avoidance
Fear of choking/vomiting
No abnormal cognitions
No morbid preoccupation
No organ brain disease (psychosis)
behavioral identifiers as “secretive eating, food seeking in response to negative affect
and food hoarding.”
There is much empirical support for the criticisms made by Bravender et al. For
example, Madden, Morris, Zurynski, Kohn, & Elliot (2009) found that when the
DSM-IV diagnostic criteria for eating disorders were applied to children hospitalized
with early onset eating disorders (EOEDs), only 38% met the criteria for anorexia
nervosa. There were also inconsistencies, in that although 67% met both psychological
criteria, only 51% met the weight criteria, despite the fact that 61% had evidence of
life-threatening complications of malnutrition. Similarly, in another study, Pinhas
et al. (2011) found that although 47% required hospitalization, only 62% met DSM
criteria for anorexia nervosa, while many, although medically compromised, did not
meet criteria.
The importance of early diagnosis and intervention is crucial for children and youth
whose bodies and brains are still in the process of development. As was discussed
in Chapter 2, although the young adolescent’s brain is highly sensitive to risky and
emotive situations, neural development of areas of cognitive control are not mature
until the end of adolescence and early adulthood. Therefore, malnutrition can seriously compromise brain development, and can also threaten physical and emotional
responses. From a physical perspective, loss of bone density can compromise future
growth trajectories, while other physical changes, such as metabolism and thyroid
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Clinical and Educational Child Psychology
levels, can cause the bodily system to malfunction, in an attempt to compensate for
malnutrition (Hamilton, 2007).
Prevalence of eating disorders A recent survey of over 10,000 adolescents in the
United States revealed lifetime prevalence rates for anorexia nervosa (0.3%), bulimia
nervosa (0.9%), and binge eating disorder (1.6%), and while the majority sought
treatment of some form, only a small portion actually received specific treatment for
their eating disorder (Swanson, Crow, LeGrange, Swendsen, & Merikangas, 2011).
A surveillance study in Canada targeting children five to 12 years of age found the
incidence of early onset restrictive eating to be evident in 2.6 cases per 100,000 cases
seen by pediatricians, over a two-year period. In this sample of 2453 children, the
ratio of girls to boys was 6:1, although boys demonstrated more growth delay (54.5%)
than girls (47.2%) resulting from their restricted eating habits (Pinhas et al., 2011).
A surveillance study conducted in Britain, collecting data on 0–9-year-olds, over a
14-month period, found an overall incidence rate of 3.01 per 100,000 cases: 37%
met criteria for anorexia nervosa; 1.4% for bulimia nervosa; and 43% for EDNOS. Of
those that met criteria for a diagnosis, approximately half were hospitalized (Nicholls,
Lynn, & Viner, 2011). An Australian study of early onset eating disorders in children
five to 12 years of age found national incidence to be 1.4 per 100 000 children. In
this study, the authors defined an eating disorder as “determined food avoidance plus
weight loss or a failure to gain weight during a period of growth, in the absence of
any identifiable organic cause” based on their review of criteria from the DSM, ICD,
and GOS (Madden et al., 2009, p. 410). In a sample of 44 Japanese patients (nine
to 14 years of age) diagnosed with early onset eating disorders, 50% met criteria for
restricting type anorexia nervosa; 15.9% for binge eating type anorexia nervosa; and
18.2% for bulimia nervosa of the purging type (Denda et al., 2002).
The medical complications of eating disorders cannot be over-stated. Unfortunately,
only one in 10 with the disorder will achieve a complete recovery, while approximately
50% will experience partial recovery (Herzog et al., 1999). The vast majority (90%)
with AN are female (Pate, Pumariega, Hester, & Garner, 1992), although over the
past several decades disorders of body image have grown increasingly common among
men in Western societies (Pope, Phillips, & Olivardia, 2000).
Lifetime prevalence for BN is between 1% and 3% and is significantly higher in
females than males (ratio of 10:1). Onset was once thought to occur in late adolescence
or early adulthood; however, research is pointing to earlier onset, and many individuals
with BN can go undiagnosed.
Etiology, treatment, and prevention of eating disorders
Etiology of eating disorders Eating disorders often begin with patterns of disordered
eating that can progress to dysfunction and distress. Between 9 and 11.3% of youth
demonstrate symptoms of AN or BN (Stice, Killen, Hayward, & Taylor, 1998). Causes
of eating disorders (ED) can be related to interactions among many characteristics
of a bio-psycho-social nature.
Biological model Having a relative with ED increases the risk sixfold (Strober,
Freeman, Lampert, Diamond, & Kaye, 2000). For a monozygotic twin with BN,
there is a 23% chance that the other twin will develop the disorder (Walters & Kendler,
1995). High rates of comorbidity of ED and depression are likely explained by low
levels of serotonin associated with ED and depression.
Later Onset Problems: Eating Disorders and Substance Use/Abuse
285
Cognitive and behavioral models Often self-defeating thought patterns can be
negatively reinforcing and self-perpetuating. Negative self-appraisals, maladaptive
thoughts about body shape/weight, and preoccupation with food are intricately
involved.
Parenting and family models Research has linked AN to overprotective families
that have rigid boundaries and deny underlying conflict (Minuchin, Rosman, & Baker,
1978). Within these confines, the adolescent simultaneously asserts her independence
by refusing to eat, while at the same time ensures her dependence, by thwarting
future growth and development (cessation or delaying of menstruation). By contrast,
BN often occurs in families that exhibit lack of control, open conflict, and hostility
(Fairburn, Welch, Doll, Davies, & O’Connor, 1997).
Sociocultural models The media, peer pressure, and the “thin ideal” have led to
increased body dissatisfaction among youth (Ricciardelli & McCabe, 2001). With
increasing emphasis on the Anglo-European model of beauty on television, in movies,
in magazines, and the on internet, the line between disordered eating and eating
disorders becomes increasingly difficult to distinguish (Herzog & Delinsky, 2001).
Athletic performers, especially in “elite sports” or “aesthetic sports” (diving, figure
skating, gymnastics), also feel increased pressure to be thin. Sundgot-Borgen and
Torstveit (2004) compared 1500 Norwegian elite athletes and controls and found
that 10.5% of the athletes had ED compared to only 3.2% of the controls. The rates
among those with ED included 45% with EDNOS, 36% with BN, and 11% with AN.
Treatment for AN Treatment for AN can be challenging, with the patient trying
to regain control at a time when they have likely been coerced into treatment (Patel,
Pratt, & Greydanus, 2003). Treatment often occurs in response to a crisis, as significant
weight loss results in acute or chronic medical complications (Comerci & Greydanus,
1997; Mehler & Andersen, 1999). Programs specifically designed to treat AN include
three main stages:
r
r
r
restore patients’ nutritional and metabolic state to normal;
multifaceted therapy (individual, group, family psychotherapy), nutritional counseling, and exercise management;
focus on long-term remission, rehabilitation and recovery. (Comerci & Greydanus,
1997)
Medical interventions Although the goal is to deliver service in outpatient settings
as much as possible (Pyle, 1999), the location of the treatment (hospital, out-patient)
will depend upon the severity and the extent of medical intervention required (feeding
tubes, restoring electrolyte balance).
Behavioral interventions During the acute phase of AN, behavior modification, contingency management, and activity management are the most appropriate
behavioral interventions that support a return to normalization and stabilization (Patel,
Pratt, & Greydanus, 2003).
Cognitive behavioral therapy (CBT) There is increased understanding of the need
to correct maladaptive thinking patterns in youth with AN (King, 2001). CBT programs often target the need for control and reframe attempts to gain independence in
286
Clinical and Educational Child Psychology
more positive ways (Robin, Siegel, & Moye, 1995). In their combined cognitive and
family therapy program, Robin, Bedway, Siegel, and Gilroy (1996) achieved a 64%
success rate (i.e., teens reached their ideal body weight) after 16 months of treatment,
which was maintained (by 82% of them) one year later.
Treatment for BN
Medical interventions Less than 5% of those with BN require inpatient treatment
(Phillips, Greydanus, Pratt, & Patel, 2003). However, medication management is
becoming more prevalent as antidepressants are increasingly prescribed for individuals
with BN (Caruso & Klein, 1998; Freeman, 1998; McGilley & Pryor, 1998). Antidepressants (SSRIs, such as fluoxetine (Prozac)) can assist 25–40% of those diagnosed
with BN (Mitchell et al., 2002).
Cognitive behavioral therapy (CBT) CBT is the most widely researched treatment for BN and has demonstrated long-term success (Agras & Apple, 1997; Wilson
& Fairburn, 1993). Agras and Apple (1997) reviewed more than 30 controlled studies
and found approximately 50% of clients eliminate bingeing and purging after treatment, with five-year follow-up studies indicating that improvements remain stable in
the long term. Although some of the participants in these studies report a periodic
relapse of bingeing and purging, the success rate is significant.
Interpersonal psychotherapy (IPT) IPT has also proven successful in the treatment
of BN (Fairburn, 1993). Rather than focusing on the eating disorder, IPT targets the
client’s interpersonal relationships and focuses on ways to make these more satisfactory
(Agras & Apple, 1997; Fairburn, 1993).
Family interventions Until recently, well-controlled studies of family intervention for BN were lacking. There has been some recent evidence of the potential feasibility of family therapy in the treatment of adolescents with BN, although
most studies are restricted to small sizes (Dodge, Hodes, Eisler, & Dare, 1995).
Two contemporary studies employing randomized clinical trials have demonstrated
that family treatment can benefit some adolescents with BN (Le Grange, Crosby,
Rathouz, & Leventhal, 2007; Schmidt et al., 2007). Le Grange and Lock (2007)
demonstrated the successful implementation of a manualized program proved superior to generic individual therapy, while Schmidt et al. (2007) found family therapy was superior to CBT for adolescents, but that more of the adolescents refused
to participate in the family therapy program. Clearly more research is warranted in
this area.
Prevention of eating disorders The majority of prevention programs have targeted
young females in mid- to late adolescence, and have met with limited success (StriegelMoore, Jacobson, & Rees, 1997). Several researchers have reviewed primary prevention programs that have focused on education (healthy weight management, adverse
effects of dieting) and/or assertiveness skills (resistance to societal pressures). The
consensus is that these programs increase the participants’ knowledge levels but have
either no effect on changing attitudes towards dieting, or limited impact at best
(Carter, Stewart, Dunn, & Fairburn, 1997; Piran, 1997).
Later Onset Problems: Eating Disorders and Substance Use/Abuse
287
Primary and secondary prevention
Recall that programs focusing on primary prevention target reducing the risks
and increasing the protective factors for developing ED in the population at
large. On the other hand, secondary prevention programs focus on early identification of symptoms of ED (e.g., body dissatisfaction) with the intent of
reducing the risk.
Pratt and Woolfenden (2006) reviewed 12 prevention programs matched for strict
inclusion criteria (randomization, control group), the majority of which (nine out of
12) were school-based. Their review yielded only one procedure that was successful
in reducing the risk of ED, namely, discussions and critical evaluations of media
messages regarding body image (Kusel, 1999; Neumark-Sztainer, Sherwood, Coller,
& Hannon, 2000).
Substance use and abuse
The term substance is used to refer to a drug of abuse, medication, or a toxin.
Although many different types of substances exist, there are three major categories
that substances can be grouped into: depressants (which slow down the activity of
the central nervous system (CNS)), stimulants (which increase CNS activity), and
hallucinogens (which alter perceptions and sensations).
Nature and course The DSM and ICD provide similar diagnostic criteria for two
substance disorders:
1. substance dependence;
2. substance abuse.
The classification systems also provide substance-specific symptoms for intoxication
and withdrawal.
Substance dependence occurs if there is a compulsive reliance on a substance, and
three out of the following seven symptoms are present within a 12-month period: tolerance, withdrawal symptoms, increased use and increased amounts, unsuccessful attempts
to quit, extensive time in procuring the substance, forgoing important activities, and
continued use despite adverse consequences.
Tolerance
Tolerance occurs when more of a substance is required to obtain the same
effect. For example, a novice may show signs of intoxication with very little of
a substance (one beer); however, an individual who has built a tolerance may
require several beers to achieve the same effect.
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Clinical and Educational Child Psychology
Substance abuse or harmful use is evident when recurrent and adverse consequences are caused by the substance use, and one or more of the following is present
over a 12-month period: failure to fulfill a major obligation, engaging in high-risk
behaviors, legal problems, and/or significant relationship problems. The disorders are
considered to be mutually exclusive, and cannot co-occur. If symptoms are met for
both, then substance abuse or harmful use (the more serious of the two disorders)
is diagnosed.
Issues in classification: a developmental perspective There is concern that criteria
derived for adults are not appropriate for youth. Harrison, Fulkerson, and Beebe
(1998, p. 487) argue that terms such as “tolerance” and “impaired control” are problematic when applied to adolescents, since “many adolescents initiate substance use
with out of control use,” while “withdrawal syndromes” may take years to develop.
Since experimentation with substances is somewhat anticipated in adolescence, the
severity of the problem may be unclear (Burrow-Sanchez, 2006). Winters (2001)
recommends a continuum rather than a categorical approach for evaluating substance
use in youth. A proposed continuum could be based on the following hierarchy of
involvement with substances:
r
r
r
r
r
r
abstinence;
experimental use;
early abuse;
abuse;
dependence;
recovery.
Winters considers the continuum to be fluid, with the possibility of relapse after
recovery, returning to initial stages and working through the process again, until
recovery is complete.
Adolescent substance use: an international perspective
The tendency for youth to engage in risky behavior is not a new phenomenon;
however, the nature of the risk can shift across generations. Drug use can place
youth at significant risk for negative outcomes in mental, physical, and emotional
health. Studies of experimentation and initial substance use have found increased
risk in youth that have a parent or older sibling who uses drugs (Brook, Whiteman,
Gordon, & Brook, 1990). Early exposure to alcohol or tobacco places youth at three
times the risk for later cannabis use (Wagner & Anthony, 2002).
Overall trends in drug usage There has been a concentrated worldwide effort to
increase understanding of trends in substance use. In the United States, Monitoring
the Future (MTF; Johnston, O’Malley, Bachman, & Schulenberg, 2008c) has collected
data on youth drug habits for over 30 years, and currently surveys students in Grade
8 (13 to 14 years of age), Grade 10 (15 to 16 years of age), and Grade 12 (17 to
18 years of age). In Europe, the European School Survey Project on Alcohol and Other
Drugs (ESPAD; Hibell et al., 2009) has been collecting data for the past 12 years and
currently has information on drug usage in 15- to 16-year-olds (equivalent to Grade
Later Onset Problems: Eating Disorders and Substance Use/Abuse
289
Table 11.3 Prevalence rates in percentages for substance use among youth in the United
States and Europe
Substance
Tobacco (lifetime)
Tobacco (past 30 days)
Alcohol (lifetime)
Alcohol (report being
“drunk,” intoxicated in
the last 12 months)
Binge drinking or heavy
episodic drinking*
Any illicit drug other than
cannabis (lifetime)**
Cannabis (lifetime)
Steroids (lifetime)
Inhalants (lifetime)
Tranquillizers, sedatives,
non-prescription use
(lifetime)
United States
(2007)
Grade 8
United States
(2007)
Grade 10
22.1
7.1
38.9
12.6
34.6
14.0
61.7
34.4
46.2
21.6
72.2
46.1
58
29
66
39
10.3
21.9
25.9
43
11.1
18.2
25.5
7
14.2
1.5
15.6
Tranquillizers:
3.9
Sedatives:
NA
31
1.8
13.6
Tranquillizers:
7.4
Sedatives:
NA
41.8
2.2
10.5
Tranquillizers:
9.5
Sedatives:
9.3
19
1
9
United States
Europe
(2007)
(2007)
Grade 12
15–16 years
Total = 6
Notes: *Five or more drinks in a row on the same occasion: in last two weeks (US sample), or in last 30 days
(European sample).
** Illicit drugs other than cannabis included:
US sample: Grade 12 group: LSD, other hallucinogens, crack, other cocaine, or heroin; or any use of other
narcotics, amphetamines, sedatives (barbiturates), or tranquilizers not under a doctor’s orders. For eighth
and tenth graders only: the use of other narcotics and sedatives (barbiturates) has been excluded since these
groups tend to over-respond (misinterpreting it as any prescribed medications).
European sample: amphetamines, cocaine, crack, ecstasy, LSD and heroin.
Sources: Johnston, O’Malley, Bachman, & Schulenberg (2008a, 2008b); Hibell et al. (2009).
10 in the US sample) from 35 countries. A comparison of reported drug usage for
2007 is available in Table 11.3.
Prevalence rates
Prevalence rates can provide information about the rate of occurrence of an
event over the span of one’s lifetime (lifetime prevalence), or various other
time periods (e.g., annual prevalence, 30 days, two weeks, etc.).
The highest lifetime prevalence rates reported by American students enrolled in
Grade 10 include: alcohol (61.7%), tobacco (34.6%), cannabis (31%), any illicit drug
other than cannabis (18.2%), and inhalants (13.6%). Among European youth (15
to 16 years of age), the highest lifetime prevalence rates were reported for: alcohol
(66%), tobacco (58%), cannabis, (19%) and inhalants (9%). Compared to similar-aged
American peers, European youth report significantly higher rates of tobacco use, and
significantly lower rates of cannabis use and illicit drug use. MTF collects data on
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Clinical and Educational Child Psychology
sedatives only for senior students (Grade 12); however, use of tranquillizers in Grade
10 (7.4%) is still higher than the combined use of tranquillizers and sedatives in
European youth (6%).
Trends in the United States In the United States, trends show a decline in drug
usage and stabilization for the majority of areas assessed, with the exception of
MDMA (ecstasy), which had been declining significantly since 2000. Rates now show
a gradual increase in use in the upper grades, with increased approval ratings among
eighth graders, signs that researchers suggest may predict that the drug is making a
“comeback.”
Trends in Europe The ESPAD survey reports the most stable trends (no further
increases) are evident in the United Kingdom, Finland, Iceland, Ireland, and Sweden,
while increased substance usage trends are evident in the Czech and Slovak republics.
Alcohol Lifetime prevalence for alcohol was the highest reported substance in the
ESPAD (Hibell et al., 2009) and MTF (Johnston et al., 2008c) surveys. MTF rates
show increased consumption with age, from eighth grade (38.9%) to tenth grade
(61.7%) to twelfth grade (72.2%). Half of the ESPAD sample reported being intoxicated over their lifetime, while 39% were intoxicated within the last 12 months. The
MTF reports 12.6% of eighth graders, 34.4% of tenth graders, and almost half of
twelfth graders were intoxicated within the previous year. Data were also collected
on binge drinking or heavy episodic drinking (consuming five or more drinks on a
single occasion). The MTF survey reports that overall use of alcohol has declined over
the years and remains relatively stable, with the greatest decline from previous surveys
in eighth graders who also reported experiencing more difficulty with the availability
of alcohol.
Although the ESPAD survey found the majority of prevalence rates for alcohol consumption were unchanged from previous surveys, heavy episodic drinking indicated a
small but continuous increase, especially in girls, who went from 35% (2003) to 42%
(2007).
Outcomes of alcohol use Intoxication is associated with increased risk for accidents,
injury, violence, and suicide attempts. In their study of over 1400 youth (14 to 18 years
of age), Spirito, Jelalian, Rasile, Rohrbeck, & Vinnick (2000) found that 21% of males
and 15% of females had had at least one alcohol-related injury. Student reports (Hibell
et al., 2009) of alcohol-related problems include: serious parent conflict (15%), poor
school performance (13%), serious problems with friends (higher among girls), and
getting into physical fights or having problems with the police (higher among boys).
Risks for alcohol use Bahr, Hoffmann, and Yang (2005) found that increased risk
for alcohol consumption was related to parent tolerance (80%) and sibling drinking
(71%), while risk for binge drinking doubled as the number of close friends who also
drank increased.
Tobacco Since 2001, tobacco use in children and youth in the eighth and tenth grades
has been declining (Johnston et al., 2008c). However, the National Survey on Drug
Use and Health (SAMHSA, 2008) reports that tobacco use increases dramatically
Later Onset Problems: Eating Disorders and Substance Use/Abuse
291
between 12 (8.5%) and 19 years of age (68.7%). The ESPAD survey reports that 58%
of students had reported smoking at least once, while 29% had had a cigarette within
the past month. About 7% said they started smoking at 13 years of age or younger.
Rates for early onset smoking were highest for the Czech Republic, Estonia, Latvia,
and the Slovak Republic (about 13%), and least common in Greece and Romania
(about 3%). Despite significantly higher rates of smoking than in the United States,
the ESPAD data revealed a decline in smoking in the majority of countries relative to
previous surveys.
Hawkins, Hill, Guo, & Battin-Pearson (2002) found that lower risk of tobacco
initiation was associated with stronger maternal bonding, while higher risk was related
to acceptance of smoking in the child’s peer group.
Cannabis (marijuana) Cannabis is derived from the cannabis plant which is dried
and rolled into cigarettes; hashish oil is a more concentrated form. The chemical
most active in cannabis is THC (delta-9-tetrahydrocannabinol), the potency of which
has increased significantly, from concentrations of 1–5% in the 1960s to current levels
of 10–15% (DSM-IV-TR; APA, 2000, p. 235).
Cannabis use among youth
The World Youth Report (UN, 2003, p. 159) states that in several countries (Australia, Canada, France, Ireland, the United Kingdom, and the United States)
cannabis use has been normalized with over 25% of secondary school students
reporting use in the past year.
Cannabis is the most prevalent illicit drug used by youth (Hibell et al., 2009;
Johnston et al., 2008c). Wide variation in cannabis use was found among countries
participating in ESPAD. The highest prevalence rates were in western Europe, with
the Czech Republic and the Isle of Man reporting that one out of six students had
used cannabis within the previous 30 days. Lifetime prevalence rates among American
youth 15 to 16 years of age (31%) were significantly higher than the overall average for
their European peers (19%), while rates for 17- to 18-year-old American youth were
even higher (41.8%), yet rates show a gradual decline for all ages since 1996 (Johnston
et al., 2008c). Cannabis, alcohol, caffeine, and nicotine use are often evident early in
adolescence and are linked to the development of dependency on other substances,
which has led to speculation that cannabis may be a gateway drug for other substances
(Hall & Lynskey, 2005).
Inhalants There are over 1000 different household and commercial products that
can be abused by sniffing, inhaling, or “huffing” (inhaling through one’s mouth)
to produce an intoxicating effect. The majority of inhalants act as a depressant, slowing down the central nervous system, and can lead to unconsciousness or Sudden
Sniffing Death Syndrome – especially associated with butane, propane, and aerosols.
Table 11.4 presents a list of inhalants and prevalence rates for youth who initiated
inhalant use in the previous 12 months, based on combined data for 2002 to 2006
collected by the National Survey of Drug Use and Health (NSDUH; SAMSHA, 2008).
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Table 11.4 Category of inhalants and percentage usage for youth initiates aged 12 to 17 in
the United States, 2002–2006
Category of inhalant
Types of inhalants
Percentage usage
Volatile solvents
Correction fluid, degreaser, or cleaning fluid
Lacquer thinner or other paint solvents
19.4
12.5
Glue, shoe polish, toluene
Amyl nitrite, “poppers,” locker room
odorizers, “rush”
29.6
15.3
Gasoline or lighter fluid
Nitrous oxide or whippets
Lighter gases, such as butane or propane
25.7
22.7
8.7
Spray paints
Other aerosol sprays
24.4
20.5
Nitrites
Gases
Aerosols (sprays)
Source: SAMHSA (2002–2006).
There is worldwide concern regarding inhalant abuse, especially in poorer communities. In Africa, inhalants and cannabis appear to be the illicit substances most
commonly used by youth, while a reported 24% of nine- to 18-year-olds living in
poverty in São Paulo, Brazil, admit to using inhalants (UN, 2003).
Inhalant use among American eighth graders (13- to 14-year-olds) reached an alltime high (21.6%) in 1995, and has been declining since that time until a resurgence
in 2005 (17.1%). In 2007, rates for tenth graders (who would have been in the
eighth grade in 2005) increased to the highest rates for this age group since 2001
(15.2%). European youth (Hibell et al., 2009) from Cyprus, the Isle of Man, Malta,
and Slovenia reported the highest prevalence rates for inhalant use in 2007 (16%),
while the lowest rates were evident in Bulgaria, Lithuania, and the Ukraine (3%).
Gateway drugs Researchers have questioned whether certain drugs act as a potential
gateway (by initiating the user to other drugs). Drug use in the United States has
for the most part revealed the trajectory from legal drugs (tobacco and alcohol)
to illegal drugs (cannabis) and other illicit drugs (hallucinogens, club drugs) with
the most serious drugs, heroin and cocaine, occurring latest (Kandel, 2002). Recent
information about inhalant use suggests that this drug may be the first drug used by
many due to ease of availability.
Generational forgetting
Johnston, O’Malley, and Bachman (2006) suggest that a new wave of drug
users can rediscover drugs abandoned by previous generations due to adverse
effects, a phenomenon they refer to as generational forgetting. The researchers
suggest this phenomenon can explain increased inhalant use in 2005 and the
recent increase in the use of MDMA (ecstasy).
Later Onset Problems: Eating Disorders and Substance Use/Abuse
293
Vulnerability and risk for drug use The European Action Plan on Drugs lists several
factors that increase the risk for drug abuse, including poor school achievement, lack
of social and life skills, school exclusion and non-attendance, engaging in delinquent
activities, self-destructive behaviors, aggression, and anxiety (EMCDDA, 2003).
A study of over 1500 Finnish adolescent twins revealed that early onset depressive
disorders predicted daily smoking, smokeless tobacco use, frequent alcohol use, and
recurrent intoxication (Sihovla et al., 2008).
Movies and alcohol use
Exposure to popular American movies that depict drinking is related to early
onset teen alcohol use (Sargent, Willis, Stoolmiller, Gibson, & Gibbons, 2006).
Increases in substance use often coincide with the onset of other comorbid disorders (Ferdinand, Blum & Verhulst, 2001). Many disorders can place youth at risk
for substance use, including: ADHD, depression, disruptive behavior disorders, eating disorders, and anxiety disorders (Kendler, Gallagher, Abelson, & Kessler, 1996;
Loeber, Farrington, Stouthamer-Loeber, & Van Kammen, 1998).
Etiology, treatment, and prevention of substance use/abuse
Etiology From a biological perspective, children of alcoholics have a higher risk
for alcohol abuse and dependence compared to peers (Cadoret, Yates, Troughton,
Woodworth, & Stewart, 1995). Many drugs impact dopamine which produces a
pleasurable effect. An abnormal dopamine receptor (D2) has been found in most
alcoholics and half of those addicted to cocaine (Lawford et al., 1997). From a
behavioral perspective, drug usage can be self-rewarding and relieve tension, causing
a greater tendency to self-medicate to reduce stress. From a sociocultural perspective,
having a close friend who uses alcohol, tobacco, or cannabis, increases the risk for
subsequent use (Maxwell, 2002).
Treatment programs Group treatments are the most common approach for substance
use problems (Khantzian, 2001); however, the concern of possible iatrogenic effects
when aggregating youth with similar problems represents a serious treatment challenge
(Dishion, McCord, & Poulin, 1999; MacGowan & Wagner, 2005).
The 12-step treatment models developed by Alcoholics Anonymous (AA) and
Narcotics Anonymous (NA) consider addiction as a progressive disease that requires
abstinence. Youth who attend 12-step treatment programs have better outcomes than
youth who do not seek treatment (Kassel & Jackson, 2001). Other forms of treatment
that have been successful include CBT with a relapse prevention component (Liddle
& Hogue, 2001) and CBT or multisystemic therapy (MST) programs that include
family in the treatment process (Donohue & Azrin, 2001; Henggeler, Schoenwald,
Borduin, Rowland, & Cunningham, 1998).
Prevention programs Primary prevention or universal prevention programs provide “resistance training,” promote well-being, and attempt to curtail or delay the
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onset of substance use. Most are school-based programs that provide information
about the harmful effects of drugs, and how to be more assertive in resisting drugs
when they are offered. However, despite the fact that federal funds have been available since 1994 for the use of empirically supported programs, 75% of schools in the
United States continue to use programs that have not been supported by research
(Ringwalt et al., 2002).
The DARE program
The most common “prevention program” used by schools in the United States
is the Drug Abuse Resistance Education Program (DARE) which has been extensively researched, but found ineffective in the prevention of drug use and abuse
(West & O’Neal, 2004).
Global Initiative Project Several worldwide initiatives have been aimed at the
prevention of substance use in youth. The Global Initiative Project on Primary
Prevention of Substance Abuse is a joint project of the United Nations Office
on Drugs and Crime (UNODC) and the World Health Organization (WHO),
which was implemented in eight countries between 1998 and 2003. The project
involved community outreach in three regions: Southern Africa (South Africa,
Tanzania, and Zambia); Central and Eastern Europe (Belarus and Russia), and
South-east Asia (the Philippines, Thailand and Vietnam). The aim was to develop
good practices in the area of primary prevention through community mobilization, working with local organizations, and providing them with training and financial and technical support. Readers can visit the website for additional information
(http://www.who.int/substance_abuse/activities/global_initiative/en/).
The World Youth Report (United Nations, 2003) emphasizes incorporating an
interactive group process as part of the prevention programs to engage youth in peer
activities such as “role playing, simulations, service learning projects, brainstorming,
cooperative learning and peer-to-peer discussions to promote active participation by
youth” (p. 166) to provide opportunities for youth to clarify their beliefs, and to
practice skills in conflict resolution, assertiveness, and communication.
The National Institute on Drug Abuse (NIDA) released the second edition of Preventing Drug Use among Children and Adolescents: A Research-Based Guide (NIDA,
2003). The document highlights important family components (drug awareness; parent skills training; increased monitoring and supervision; and the need for consistent
discipline and limit-setting) and school components, such as the need to focus on increasing age-appropriate behaviors and reducing maladaptive behaviors. At the preschool
level, the focus is on reduction of aggression and increases in self-control; elementary
school students should acquire increased emotional awareness, social problem solving, communication, and academic skills; in secondary school emphasis should be on
improved study habits, academic support, drug resistance skills, self-efficacy, and the
development of anti-drug attitudes. The guidelines recommend combined family and
school programs to enhance cohesiveness and a sense of belonging in the community.
Later Onset Problems: Eating Disorders and Substance Use/Abuse
295
Life Skills Training (LST) LST has been implemented in 29 inner-city schools
in New York and has successfully lowered rates of alcohol, cigarette, and inhalant
abuse among at-risk minority students in the seventh grade who have poor academic
performance and associations with substance-abusing peers (Botvin, Griffin, Diaz, &
Ifill-Williams, 2001; Griffin, Botvin, Nichols, & Doyle, 2003). Fifteen lessons (45
minutes) are embedded into the regular curriculum and focus on the development of
social skills, drug refusal, and personal management.
Best practices in prevention Montoya, Atkinson, and McFaden (2003) reviewed
school-based programs, family-based programs, and community-based programs over
the past 20 years to identify best practices in prevention programs for youth. Six factors
emerged that were key to successful programs:
r
r
r
r
r
r
good parenting (strong family bonds, and parental involvement in school-based
drug prevention programs);
skill development (resistance skills, social skills) and normative education (awareness of faulty beliefs that drug use is acceptable and prevalent);
counteracting peer influence to engage in substance-related activities;
retention of program participants and prevention of drop-out from the program;
anti-drug media campaigns;
support of laws and policies for a drug-free environment.
The authors identified three important steps in prevention program development:
Step 1. Isolate the relevant risk factors.
Step 2. Select the necessary characteristics to overcome the risks.
Step 3. Determine the best environment (home, school, community) for conducting
the program. (Montoya et al., 2003, p. 81)
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12
Child Maltreatment and
Self-Injurious Behaviors
Chapter preview and learning objectives
Child maltreatment
Definition and prevalence rates
Historical background
Definition of child maltreatment
Prevalence rates of child maltreatment
Types of maltreatment
Physical maltreatment
Definition and prevalence rates
Characteristics and outcomes
Sexual maltreatment
Definition and prevalence rates
Characteristics and outcomes
Emotional or psychological maltreatment
Definition and prevalence rates
Characteristics and outcomes
Neglect
Definition and prevalence rates
Characteristics and outcomes
Multiple maltreatment
Child maltreatment: child and family characteristics
Child characteristics: risks and protective factors
Family characteristics: risks and protective factors
Prevention and intervention for child maltreatment
Self-injurious behaviors
Definition and prevalence rates
Characteristics and populations at risk for self-injury
Child maltreatment and self-injury
Clinical populations and self-injury
Other risk factors
Intervention and treatment
References
Clinical and Educational Child Psychology, First Edition. Linda Wilmshurst.
© 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.
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Chapter preview and learning objectives
Historically, “child abuse” was primarily associated with thoughts of physical abuse
or severe cases of child neglect; however, more contemporary views of child maltreatment focus on four primary sources of maltreatment: physical, sexual, emotional/psychological, and neglect. There are also frequent reports of multiple maltreatment, where a child is subjected to more than one form of abuse. The chapter
has been placed in close proximity to the chapter on trauma, since many of the children suffering from abuse develop symptoms of post-traumatic stress disorder (PTSD)
which will be address in Chapter 13. Categorically, although most countries agree on
the four types of abuse, there is wide variation as to what constitutes abuse within
those categories. For example, definitions of physical abuse differ significantly depending on the cultural practices of disciplining children that are acceptable. Due to these
variations, the definitions for maltreatment in this chapter are derived from definitions
found in the World Report on Violence and Health developed by the World Health
Organization (WHO; Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002). This chapter
will provide readers with an increased understanding of:
r
r
r
r
the nature and characteristics of different types of abuse and maltreatment;
outcomes for children exposed to maltreatment;
prevalence rates for the different types of abuse, internationally;
initiatives in primary, secondary, and tertiary prevention.
Although not all children who engage in self-injurious behavior (self-inflicted injuries
without suicidal intent) suffer from abuse, many do, and therefore information on this
subject is also included within this chapter.
Child maltreatment
Definition and prevalence rates
Historical background Prior to the nineteenth century, childhood was not considered
to be a unique period of development (children were seen as miniature adults) and
child-rearing was based on prevailing religious, cultural, and social influences dominated by theories of social control. Within this context, children were considered to
be chattel; parents had sole ownership of them and could do as they pleased with them
(Scannapieco & Connell-Carrick, 2005). However, by the fifteenth century, scholars
and educators were beginning to see children in a different light, although this only
benefitted children of privilege, since poor children were still in high demand for
the labor force. Philosophers in Europe, in the seventeenth and eighteenth centuries,
debated parents’ role in child rearing, voicing opinions at the ends of two extremes.
In England, John Locke was of the opinion that children were born into this world as
a blank slate (tabula rasa), and it was the parents’ duty to nurture and teach the child.
In France, Jacques Rousseau pleaded with parents to let nature take its course, and let
the children grow without interference (laissez faire). The nature nurture debate has
continued since that time.
With the arrival of the industrial revolution and child labor laws, advocates began
to “save” the children from the hardship of the workforce; however, in the process,
Child Maltreatment and Self-Injurious Behaviors
303
many were abandoned by their parents, because they were no longer of use and
became a hindrance. Street children often ended up living in appalling conditions
in “almshouses” or poorhouses, which were eventually replaced by orphanages and
ultimately foster home placements (Scannapieco & Connell-Carrick, 2005).
Definitions of maltreatment today differ significantly from what was historically
considered to be abuse or neglect, and definitions vary depending on culture, the
prevailing social policy, and the jurisdiction, and among different professionals and
organizations, which can often make it difficult for the workers involved (Giovannoni,
1989). Similarly, as will soon be addressed, lack of uniformity in definitions also causes
problems in estimating prevalence rates for child maltreatment and in collating data
across research studies for the purposes of conducting a meta-analysis.
Historically, the term “child abuse” was primarily associated with thoughts of physical abuse or severe cases of child neglect. One of the first speculations about the
existence of emotional neglect was recorded by L. Emmett Holt in his book The
Diseases of Infancy and Childhood, in which he described conditions of infant “wasting” and malnutrition that could be associated with clinical factors, a term he later
referred to as “failure to thrive” in the tenth edition of his text which was published
in the mid-1930s (Holt, as cited in Schwartz, 2000). Several years later, René Spitz
(1946) drew attention to the consequences of emotional neglect when he wrote of
his observations of institutionalized infants who seemed to waste away despite having
their physical needs met, a condition referred to as marasmus. Spitz referred to the
infants’ listlessness and continual sobbing as an early form of depression which he
labeled anaclitic depression.
Failure to thrive or “maternal deprivation syndrome” (later renamed “parental
deprivation syndrome”) was finally recognized by the American Psychiatric Association (APA) when “reactive attachment disorder” was officially entered into the third
edition of the Diagnostic and Statistical Manual of Mental Disorders in the late 1960s
(Schwartz, 2000). Also at this time, Kempe, Silverman, Steele, Droegemueller, and
Silver (1962) published their renowned article on the “battered child syndrome”
wherein they claimed that “physicians have a duty and responsibility to the child to
require a full evaluation of the problem and to guarantee that no expected repetition
of trauma will be permitted to occur” (p. 17).
It is now recognized that child maltreatment can occur as a result of acts of “commission,” such as physical, sexual, or emotional abuse, or acts of “omission,” such as
cases of severe emotional, educational, or physical neglect that jeopardizes a child’s
health and well-being (Ronan, Canoy, & Burke, 2009).
Definition of child maltreatment Despite differences in the exact wording of different
definitions, most agree that maltreatment predominantly refers to acts of abuse that
can occur in four ways: physical abuse, neglect, sexual abuse, and emotional abuse.
However, what is considered to be subsumed under these categories may vary widely,
as will soon become evident. Acts of maltreatment can be perpetrated by parents,
caregivers, siblings, or other significant individuals in the child’s life, and more often
than not by individuals whom the child knows and trusts.
According to the APA (1996), children who experience maltreatment can be conflicted for several reasons, including: ambivalence between wanting to put an end to
the violence but feeling a sense of loyalty and belongingness to the perpetrator; the
abuse may be followed by reconciliation and affection which reinforces the child’s
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Clinical and Educational Child Psychology
hope that the situation has changed for the better; and abuse and power tend to
increase over time, increasing the child’s threshold for victimization.
According to the WHO, any definition of child maltreatment “must take into
account the differing standards and expectations for parenting behaviour in the range
of cultures around the world” and with this underlying premise in mind, the WHO
drafted the following definition of child abuse and maltreatment:
Child abuse or maltreatment constitutes all forms of physical and/or emotional illtreatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or
dignity in the context of a relationship of responsibility, trust or power.
(Krug et al., 2002, p. 59)
Prevalence rates of child maltreatment
Problems in obtaining accurate prevalence rates Accurate prevalence rates for
maltreatment are difficult to obtain and compare for several reasons, including differences in: definitions of maltreatment; types of maltreatment included in studies; population sampled (socio-economic status, education level, community versus clinic);
the type of statistics reported; the measures used to obtain the data; and whether
prevalence rates are reported as annual or lifetime rates. In addition, the “accuracy”
of estimates may be questionable since not all incidents of child abuse are reported to
authorities (Feather & Ronan, 2009).
Some prevalence rate statistics In the United States, it is estimated that 10 out of
every 1000 children will experience some form of maltreatment (USDHHS, 2010). In
the United Kingdom, using a broad definition of maltreatment which includes bullying
as well as family-based violence, it was reported that about one million out of 13
million children are victims of maltreatment (Hobbs, 2005). In the United States and
the United Kingdom, when data include information on non-family physical assault,
such as bullying, approximately 20% of children and youth admit to being physically
threatened (bullying) outside the family context (Cawson, Wattam, Brooker, & Kelly,
2000). However, based on data acquired in the United Kingdom, Cawson et al.
(2000) report that despite elevated levels of bullying, children continue to be most
at risk within the context of their own family, and that among the different forms
of maltreatment, children are more at risk of physical and emotional abuse than
sexual abuse.
In the Netherlands, adopting the methodology used to determine prevalence rates
in the United States (National Incidence Studies (NISs), which will be discussed
shortly), Euser, van IJzendoom, Prinzie, and Bakermans-Kranenburg (2010) gathered data about child maltreatment cases reported by professionals, as well as those
cases registered with the Dutch Child Protection Services (CPS). The overall rate of
maltreatment in the Netherlands was reported as 30 cases per 1000 children. Euser
et al. (2010) report that one of the most disturbing findings in their study was that
only 12.6% of the total number of maltreatment cases were ever reported to the CPS.
Hauser, Schmutzer, Brahler, Glaesmer, and Roseveare (2011) surveyed youth 14
years of age and older in a representative sample of over 2500 persons in Germany. Results revealed the following prevalence rates for different types of abuse:
Child Maltreatment and Self-Injurious Behaviors
Table 12.1
305
The Fourth National Incidence Study of Child Abuse and Neglect (NIS-4)
Total (Endangerment Standard) = 2,905,800 (almost 3 million)
476,600
Physical
abuse
57%
Abused 835,000
Neglected 2,251,600
29%
77%
302,600
Emotional
abuse
36%
180,500
Sexual
abuse
22%
1,192,200
Physical
neglect
53%
1,173,800
Emotional
neglect
52%
360,500
Educational
neglect
16%
Source: Sedlak et al. (2010).
1.6% reported severe emotional abuse; 2.8% reported severe physical abuse; and 1.9%
reported severe sexual abuse. In this study, neglect was subdivided into physical and
emotional components, with 6.6% reporting severe emotional neglect and another
10.8% reporting severe physical neglect.
Comparing lifetime prevalence rates for the United States, the United Kingdom,
and New Zealand reveals comparable rates, with average percentages for sexual abuse
approximately 10% and physical abuse within the family context between 7% and 9%
(Ronan, Canoy, & Burke, 2009).
The Fourth National Incidence Study of Child Abuse and Neglect The most
recent and comprehensive collection of data on child maltreatment in the United States
is the Fourth National Incidence Study of Child Abuse and Neglect (NIS-4; Sedlak
et al., 2010) which has recently completed analysis of data collected during 2005–
2006, representing 6208 reports submitted by “sentinels” (designated staff in schools,
day care centers, hospitals, etc.) and 10,667 forms completed by participating CPS
agencies. For the purposes of data analysis, the NIS used a definition of maltreatment
that satisfied one of two conditions: the Harm Standard, an objective measure of
demonstrable harm of abuse or neglect; or the Endangerment Standard, which
includes all children who meet criteria for the Harm Standard, but also includes
children who, although “not yet harmed by abuse or neglect,” are considered to
be in danger of abuse or neglect. The latter standard also allows for inclusion of
perpetrators other than parents in certain categories. The results of the latest data
analysis are presented in Table 12.1.
The total number of children who were reported to have been abused, neglected,
or endangered is almost three million, with a ratio of one out of every 25 children.
These rates are not appreciably different from rates that were collected for the NIS-3
in 1993 (Sedlak & Broadhurst, 1996), although the distribution has changed, with
categories of physical, sexual, and emotional abuse declining in percentage rates in
the interim (29%, 47%, and 48%, respectively) and rates for emotional neglect more
than doubling with an 83% increase in rate. The report suggests that increased rates
may reflect the heightened awareness of emotional neglect since the previous report.
However, increased research is required in this area to provide further insight. Based
on results of this report, physical and emotional neglect surface as the predominant
forms of maltreatment for children.
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Clinical and Educational Child Psychology
With respect to physical and emotional neglect, the NIS-4 (Sedlak et al., 2010)
reports that prevalence rates were lowest for the oldest children (15- to 17-year-olds)
and highest for children in the six- to eight-year-old category. In addition, compared
to the NIS-3, researchers found increases in the reported rates of victimization for the
youngest children (0–2 years of age) for sexual abuse (Harm Standard) and overall
maltreatment (Endangerment Standard) although it is unclear, at this time, why this
is so.
Types of maltreatment The four major types of maltreatment are: physical, sexual,
emotional/psychological, and neglect. Multiple maltreatment includes various combinations of the major areas. The following discussion will address some of the most
common characteristics that have been identified with each form of abuse. However, it
is important to emphasize that many studies do not distinguish between the different
forms of abuse. For this reason, the concluding section on child maltreatment will
provide an overview of risks and protective factors as they relate to child maltreatment
in a generic sense, considering child and family characteristics in terms of cognitive,
behavioral, social, medical, and psychiatric outcomes that have been associated with
child and adolescent maltreatment.
Spare the rod and spoil the child
The WHO states that “corporal punishment of children – in the form of hitting, punching, kicking or beating” is socially accepted and is legal in at least
60 countries for juvenile offenders, and in at least 65 countries for use in schools
and other institutions, and legally acceptable in the home in all but 11 countries.
The WHO recognizes that corporal punishment continues to exist despite the
United Nations Convention on the Rights of the Child which was developed
to protect children from physical and mental violence and is incompatible with
corporal punishment (Krug et al., 2002, p. 60).
Physical maltreatment
Definition and prevalence rates The WHO defines physical abuse of a child as “those
acts of commission by a caregiver that cause actual physical harm or have the potential
to harm” (Krug et al., 2002, p. 60).
Philosophically, the use of corporal punishment has been widely debated on moral,
religious, and political grounds (Benjet & Kazdin, 2003; Gershoff, 2002). On the one
hand, parents in some cultures and geographical locations see corporal punishment
as a typical means of disciplining children. For example, researchers found that in the
United States, 94% of parents of toddlers admitted to using corporal punishment for
issues of compliance (Straus & Stewart, 1999). Yet, in other areas of the world (e.g.,
Austria, Finland, Germany, Sweden), corporal punishment is illegal and is banned from
use in the home and school (Gershoff, 2002; Kazdin & Benjet, 2003). Opponents
of the use of corporal punishment cite countless negative outcomes that have been
Child Maltreatment and Self-Injurious Behaviors
307
associated with the use of corporal punishment, including: child aggression, antisocial
behavior, and increased tendencies to be victimized (Gershoff, 2002). Other studies
have found that children with difficult temperaments (hyperactivity and impulsivity)
are particularly at risk for parental use of harsh discipline; however, at the same time,
these children are among the most vulnerable to the effects of this form of discipline
by demonstrating increased aggressive behavior towards peers (Colder, Lochman, &
Wells, 1997).
Global estimates of physical abuse vary widely based on the population sampled
and the methods of data collection used. For example, 37% of children surveyed in
Egypt claimed to have been beaten or tied up by their parents, while two-thirds of
parents in the Republic of Korea admitted to whipping their children; 45% reported
that they had hit, kicked, or beaten their children. Almost half of the parents surveyed in Romania admitted to beating their children regularly. The World Studies
of Abuse in the Family Environment (WorldSAFE) collected data from mothers on
parenting practices in four locations: Chile, Egypt, rural India, and the Philippines.
Data are published in the WHO World Report on Violence and Health (Krug et al.,
2002) and are reported alongside information collected in the United States using the
same measure (the Parent–Child Conflict Tactics Scale). Results of the data collection for moderately severe and severe forms of physical punishment are presented in
Table 12.2. As is evident in the table, spanking on the buttocks is the most common
form of punishment, globally, with the exception of Egypt, where shaking, pinching,
or slapping are more common forms of punishment.
Characteristics and outcomes Physical abuse is most likely to occur at the extremes
of the age continuum, with 51% of abuse related to children under seven years of age
(26% are three years of age or younger) and 20% occurring in adolescence (USDHHS,
2009).
Children who are physically abused can evidence cognitive and behavioral changes,
which are apparent in disorganized and disoriented attachment patterns (Lyons-Ruth
& Jacobvitz, 1999) or avoidant attachment patterns because the primary caregiver
is neither a safe haven nor a source of security. Trauma enactment may take the
form of child’s play (abusing dolls or stuffed animals) or may show up in children’s
drawings (Gaensbauer & Siegel, 1995). Cognitively, although not all children
demonstrate delays, studies have found deficits in verbal and memory skills, as well
as in academic achievement, in children with histories of physical abuse (Friedrich,
Einbender, & Luecke, 1983; Hughes & Graham-Bermann, 1998). Prasad, Kramer,
and Ewing-Cobbs (2005) found that preschoolers who had been physically abused
scored significantly lower than non-abused peers on tests of expressive and receptive
language, motor skills, and general cognitive functioning, while Lansford et al.
(2002) reported lower grades in language arts and standardized tests for adolescents
with a history of abuse.
Munchausen by proxy syndrome
The DSM (APA, 2000) lists Munchausen by proxy syndrome as a fictitious
disorder that relates to a parent (usually the mother) inducing illness in a child
308
Table 12.2
Clinical and Educational Child Psychology
Discipline and punishment by country: incident rates for the past six months
Physical punishment
Chile
Moderately severe forms of punishment
Spanking on buttocks
51
Hit the child on buttocks
18
(with object)
Slapped the child’s face or
13
head
Shook the child
39
Pinched the child
3
Pulled the child’s hair
24
Hit the child with
12
knuckles
Twisted the child’s ear
27
Forced the child to kneel
0
or stand in an
uncomfortable position
Put hot pepper in the
0
child’s mouth
Severe forms of punishment
Hit the child with an
4
object
Kicked the child
0
Burned the child
0
Beat the child
0
Threatened the child with
0
a knife or gun
Choked the child
0
Verbal or psychological punishment
Yelled or screamed at the
84
child
Called the child names
15
Cursed at the child
3
Refused to speak to the
17
child
Threatened to kick the
5
child out of the
household
Threatened abandonment
8
Threatened evil spirits
12
Locked the child out of
2
the Household
Non-violent disciplinary practices
Explained why behavior is
91
wrong
Took privileges away
60
Told child to stop
88
Gave child something to
71
do
Made child stay in one
37
place
Egypt
Rural India
Philippines
United States
29
28
58
23
75
51
47
21
41
58
21
4
59
45
29
25
12
17
29
28
20
60
23
8
9
5
*
*
31
6
16
2
31
4
*
*
2
3
1
*
26
36
21
4
2
2
25
0
10
1
*
1
6
0
3
1
0
0
0
0
1
2
1
0
72
70
82
85
44
51
48
29
*
31
24
0
15
17
24
*
0
*
26
6
10
6
1
20
20
*
48
24
12
*
*
*
80
94
90
94
27
69
43
43
*
27
3
91
66
77
*
75
50
5
58
75
Note: *Question was not included in the survey.
Source: Krug et al. (2002).
Child Maltreatment and Self-Injurious Behaviors
309
and subjecting the child to numerous intrusive and painful medical procedures
to “cure” a fabricated illness. Children who are victims of Munchausen by proxy
suffer extensive physical and emotional abuse.
Children with a history of physical abuse also experience more medical problems,
such as failure to thrive, abdominal complaints/injuries, and brain injuries (Bruce,
1992; Ricci, 2000). In addition, these children may show higher pain tolerance (Scannapieco & Connell-Carrick, 2005) and experience delayed physical development. As
will be discussed shortly, maltreatment can result in neurodevelopmental outcomes as
neural pathways are compromised by living in a chronic state of stress. Children who
are physically abused may live in a perpetual state of fear and may produce behaviors
consistent with enacting a fight or flight response (Perry, 1997; Perry & Pollard,
1998). Infants may extinguish their crying and dissociate, if the parental response to
their cries is physical violence (Perry & Pollard, 1998). Children who live in a physically threatening environment may see the world as a hostile place and in their state
of hyperarousal may become the aggressor as a result (Perry, 1997).
Shaken baby syndrome
As was seen in Table 12.2, shaking a child is a common form of punishment.
However, when shaking involves an infant, the results can be fatal. Infants
have developed intracranial hemorrhages, retinal hemorrhages, and seizures as
a result of being shaken repeatedly. It has been estimated that about one-third
of shaken babies die as a result of their injuries (Kivlin, Simons, Lazoritz, &
Ruttum, 2000).
Early onset of physical maltreatment has been related to increased symptoms of
anxiety and depression in adulthood, compared to later onset which is associated with
increased behavioral problems (Kaplow & Widom, 2007). If children are emotionally
and physically abused prior to the age of five, they are more likely to engage in
externalizing and aggressive behaviors, while those who are neglected during this
time are more likely to develop internalizing behaviors (Manly, Kim, Rogosch, &
Cicchetti, 2001).
Sexual maltreatment
Definition and prevalence rates The WHO defines sexual abuse as “those acts where
a caregiver uses a child for sexual gratification” (Krug et al., 2002, p. 61). According
to the WHO, global lifetime prevalence rates for childhood sexual victimization range
from 20% of females to 5–10% of males. When peers are considered as perpetrators
rates increase by 9%, and when lack of physical contact is included in the definition
rates increase by 16% (Krug et al., 2002, p. 64).
Characteristics and outcomes Middle childhood is the most prevalent age for sexual
abuse, with the median age for females being 11 years of age, while the median age
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for males is eight years of age (USDHHS, 2010). The risk of sexual abuse increases if
children live without one of their birth parents for a period of time, or if the mother is
not available (Finkelhor & Berliner, 1995). Children who demonstrate inappropriate
sexual behavior may be acting out previous abuse, while sexualized behaviors can
also place the child at increased risk for future victimization (Friedrich et al., 2001).
Other factors which can place a child at risk for sexual abuse include: low self-esteem,
depression, external locus of control, introversion, and social isolation (Faust, Runyon,
& Kenny, 1995).
A number of studies have found that girls who have been sexually abused obtain
lower scores on tests of cognitive abilities and academic achievement than their peers
(Sadeh, Hayden, McGuire, Sachs, & Civita, 1993; Trickett, McBride-Chang, &
Putnam, 1994). At least one-third of children and youth who have been sexually
abused will develop post-traumatic stress disorder, (PTSD) with symptoms of dissociation as they try to mentally distance themselves from their thoughts about the
abuse (Trickett, Noll, Reiffman, & Putnam, 2001). Their sense of victimization may
result in feelings that further victimization is inevitable, leading to revictimization in
the future (Boney-McCoy & Finkelhor, 1995). In their discussion of sexual abuse,
Finkelhor and Browne (1988) present a four-stage model of the traumatic consequences of abuse, including: traumatic sexualization (age-inappropriate promiscuity
and/or avoidance of sexual intimacy), betrayal (sense of manipulation), powerlessness
(feelings of victimization), and stigmatization (feeling as if they are damaged goods).
Emotional or psychological maltreatment
Definition and prevalence rates Emotional or psychological abuse is probably the
least well defined of all the abusive situations. The WHO defines emotional abuse as:
the failure of a caregiver to provide an appropriate and supportive environment and
includes acts that have an adverse effect on the emotional health and development of
a child, such as . . . restricting a child’s movements, denigration, ridicule, threats and
intimidation, discrimination, rejection and other nonphysical forms of hostile treatment.
(Krug et al., 2002, p. 61)
According to the NIS-4 (2010), approximately one-third of children are subjected to
emotional maltreatment. Trickett, Kim, and Prindle (2011) report that youth who
are involved with CPS are often multiply maltreated, with emotional maltreatment
(54%) or emotional neglect (54%), common factors across other forms of abuse. Some
studies have included inter-parental violence (domestic violence) under the rubric of
emotional abuse (Ronan, Canoy, & Burke, 2009; Weiss, Waechter, Wekerle, & the
MAP Research Team, 2011), while other studies have suggested that emotional abuse
be related to an abusive parenting style that predicts a set of acts of omission and
commission that do not support development (Glaser, 2011). According to Glaser
(2011), the effect of emotional abuse may not be immediately apparent and may
not surface until adolescence when identity formation is thwarted as a result. The
most common forms of emotional abuse include incidences of verbal abuse, such
as “belittling, threatening and terrorizing” (Wekerle, 2011, p. 901). Examples of
emotional abuse and prevalence rates for five countries are available in Table 12.2. The
table also provides rates for non-violent disciplinary practices for the same countries.
Child Maltreatment and Self-Injurious Behaviors
311
A disturbing statistic from a Canadian study of emotional abuse revealed that
the rates for both the categories of emotional-abuse-only and emotional-neglectonly increased threefold between 1998 and 2003 (Chamberland, Fallon, Black, &
Trocmé, 2011).
Characteristics and outcomes Children who are emotionally maltreated are significantly more likely to engage in externalizing behaviors such as aggression towards peers
and delinquent behaviors (males and females), report more internalizing symptoms,
such as depression (in girls) and learned helplessness, have lower levels of self-esteem
and self-compassion, and experience more difficulty with emotion regulation than
peers (Gabarino, 2011; Herrenkohl, Egolf, & Herrenkohl, 1997; Tanaka, Wekerle,
Schmuck, & Paglia-Boak, 2011). While it is important for parents to assist their child
in developing ways to limit and regulate their emotions and behaviors through limit
setting and the use of appropriate discipline (e.g., temporary removal of privileges, or
instituting time outs), emotionally abusive parents exercise control through psychological tactics that undermine the child’s sense of emotional security and self-worth
through methods such as guilt induction, denigrating remarks, or threats regarding
the stability of family relationships, thereby obtaining power through psychologically coercive methods (Bornstein, 2006). These emotionally manipulative practices
interfere with the normal development of the child’s social, cognitive, and affective
responses (Wekerle, Miller, Wolfe, & Spindel, 2006). As a result these children may
inhibit emotional responses of distress, such as crying, for fear of retaliation; may
become more wary, hypervigilant, and fearful in the future (Klorman et al., 2003);
and may misinterpret nonverbal cues in others, such as facial expressions, with an
increased tendency to attribute a hostile bias inherent in the expressions of others, by
paying more attention to reading expressions of anger and threat than others (Pollak
& Tolley-Schell, 2003). Children who are subject to emotionally manipulative tactics
report more significant emotional distress and are more likely to develop internalizing
disorders, such as anxiety and depression, in the future (Steinberg, 2005).
Neglect
Definition and prevalence rates As with other forms of maltreatment, there are many
different definitions of neglect. The NIS-4 (Sedlak et al., 2010) collected data on
three forms of neglect (see Table 12.1), namely, physical, emotional, and educational
neglect. The overall rate of neglect according to the NIS-4 is 77% using the endangerment standard, and 61% if the harm standard is applied. Physical and emotional
neglect are among the highest rates (53% and 52%, respectively, using the endangerment standard). Some researchers consider neglect in two categories, physical and
emotional (Gustavsson & Segal, 1994), while other researchers have identified up
to five subcategories: physical, emotional, medical, mental health, and educational
(Erickson & Egeland, 2002). The WHO reports that manifestations of child neglect
can include such situations as:
non-compliance with health care recommendations, failure to seek appropriate health
care, deprivation of food resulting in hunger, failure of a child physically to thrive,
exposure to drugs and inadequate protection from environmental dangers, as well as,
abandonment, inadequate supervision, poor hygiene and being deprived of an education.
(Krug et al., 2002, p. 61)
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The WHO distinguishes between neglect and poverty, stating that neglect can occur
“only in cases where reasonable resources are available to the family or caregiver”
(Krug et al., 2002, p. 61). In Canada, based on nationally reported cases of neglect
to child welfare services, the following breakdown of cases was revealed: 19% physical
neglect, 12% abandonment, 11% educational neglect, and 48% lack of supervision
resulting in child’s physical harm (Trocmé & Wolfe, 2001).
Characteristics and outcomes In their study of 539 children with a history of neglect,
Rogeness, Amrung, Macedo, Harris, and Fisher (1985) found that neglected boys had
lower IQ scores than boys with a history of abuse, while girls whose history included
both physical abuse and neglect had lower IQ scores than peers. In their study of
over 11,000 second-grade students, Fantuzzo, Perlman, and Dobbins (2011) found
that substantiated child neglect was associated with poorer outcomes than reported
physical abuse.
Compared to all other forms of abuse, neglected children are more likely to
encounter school problems in language, reading, and mathematics, and are the most
likely to repeat a grade (Veltman & Browne, 2001). Other studies have found that
neglect is associated with higher risk for language problems (articulation, comprehension) and school readiness (Strathearn, Gray, O’Callaghan, & Wood, 2001).
Multiple maltreatment
Up to this point, the discussion has focused on different types of abuse, and the
prevalence rates and outcomes associated with the various forms of abuse and neglect.
However, it has become increasingly evident that maltreated children are often subjected to more than one form of victimization (Finkelhor, Ormrod, & Turner, 2007).
As was noted in the initial discussions of maltreatment, our understanding of the different types of abuse has produced at least four different categories of maltreatment
(physical, emotional, sexual, and neglect), and while some include domestic violence
under the umbrella of emotional abuse (Ronan, Canoy, & Burke, 2009), others prefer
to consider it as a distinct category (Edleson, 2001; Herrenkohl & Herrenkohl, 2007).
In their review of the research regarding multiple maltreatment, Herrenkohl and
Herrenkohl (2009) found evidence from a number of studies that support the notion
that children are often exposed to multiple forms of maltreatment; that is, maltreatment involving more than one of the following: physical abuse, emotional abuse,
sexual abuse, neglect, and witnessing domestic violence (Edleson, 2001; Herrenkohl
& Herrenkohl, 2007; Higgins & McCabe, 2001). There is a wide range in the estimates of cases of multiple maltreatment depending on the nature of cases studied,
and how the data were collected (case reports, versus child and parent interviews).
For example, using CPS case records, Herrenkohl and Herrenkohl (1981) found
approximately one-third of children were exposed to multiple maltreatment. However,
Cicchetti and Rogosch (1997) reported that 73.2% of their sample of 133 maltreated
children were subjected to multiple maltreatment, while McGee, Wolfe, and Wilson
(1997) found that 94% of 160 maltreated adolescents reported experiencing more
than one maltreatment type.
Although more and more researchers are recognizing that multiple forms of maltreatment may coexist for the same victim, research on the cumulative risk that this
may pose for child outcomes is lacking (Herrenkohl & Herrenkohl, 2009). However, at least one study has investigated the likelihood of experiencing another form
Child Maltreatment and Self-Injurious Behaviors
313
of maltreatment based on exposure to various forms of maltreatment. Lau et al.
(2005) report that 94% of children who experience sexual maltreatment also experience another form of abuse, while 78.7% of children who are physically abused also
experience another form of maltreatment. In their study of adult female victims of
maltreatment, approximately half of those who admitted to being maltreated as children reported two or three different forms of maltreatment (Moeller, Bachman, &
Moeller, 1993). Outcomes for children who are exposed to multiple maltreatment,
or poly-victimization, will be discussed at greater length in Chapter 13.
Child maltreatment: child and family characteristics
Child characteristics: risks and protective factors
Risk factors Researchers who have investigated age of onset of maltreatment have
found differential outcomes based on the nature of the maltreatment and its longevity
(Kaplow & Widom, 2007). Children are at the most risk for harm in the first year
of life (DfES, 2005). In the United States in 2003, 28% of all child deaths were the
result of physical abuse, and of this number almost half (44%) were children under the
age of one year (USDHHS, 2005). Globally, infants and very young children are at
greatest risk of fatalities, with fatality rates for children under four years of age more
than double the rate for those in the five- to 14-year-old category.
In the first two years of life, brain development is rapid, with increased myelination
speeding up the efficiency of neural responses, while synaptic pruning provides pathways for future learning. However, in the brains of children exposed to chronic stressful
and perhaps even violent conditions, pathways may be wired that set the stage for maladaptive responses to stress in the future. Watts-English, Fortson, Gibler, Hooper, and
DeBellis (2006) discuss how the psychobiological pathway, including neurobiological
stress response systems and neurodevelopment, can be altered by a child’s history
of maltreatment. According to Watts-English et al. (2006), brain-related changes
can mediate maladaptive “psychiatric, behavioral and neurodevelopmental outcomes
experienced by children with histories of maltreatment” (p. 718).
When children are placed in an environment of chronic stress, the sympathetic
nervous system (SNS) responds by repeatedly releasing catecholamines (norepinephrine, serotonin, dopamine) into the system, initiating a fight or flight response,
which can “influence brain maturation and neurodevelopment” (Watts-English et al.,
2006, p. 720). In addition, the serotonin system is also affected, since mass production of serotonin eventually depletes reserves and can lead to symptoms of
severe depression, suicidal ideation, and PTSD. Finally, the limbic–hypothalamic–
pituitary–adrenal axis (LHPA/HPA) releases cortisol into the bloodstream which
may result in greater cortisol production in response to novel stressors in the future.
Studies of children exposed to maltreatment have revealed physical differences in the
brains of children who had a history of maltreatment (smaller mid area of the corpus
callosum; smaller total brain volume in boys) and less volume in the prefrontal cortex
and right temporal lobe (De Bellis et al., 2002; Teicher et al., 1997).
Children with disabilities are three to four times more likely to be abused or
neglected than peers (Murphy, 2011) and three times more likely to be sexually
abused (Sullivan & Knutson, 2000). Within this broad category of disabilities, studies
have reported that children with conduct disorders are eight times more likely to be
emotionally abused and six to seven times more likely to be sexually abused than
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children without the disorder (Sullivan & Knutson, 2000). Younger children with
behavioral or mental health issues (younger than six years of age) have twice the risk
of maltreatment compared to peers.
Protective factors A young child with an easy temperament is less likely to be a target of maltreatment compared to children with difficult temperaments. Children who
have well-developed social skills and positive self-esteem, and are affectionate and cognitively higher functioning, are more likely to be protected from maltreatment (RadkeYarrow & Sherman, 1990; Wolfe, 1999). Despite being subjected to adversity, such
as maltreatment, some children do not develop psychological or social/emotional
problems and instead demonstrate resilience. In one study, between 20% and 40%
of children who were physically or sexually abused did not suffer negative outcomes
as adults; while in another study, half the maltreated children did not develop psychopathology as adults (Collishaw et al., 2007; Finkelhor, 1994).
Family characteristics: risks and protective factors
Risk factors Parents who have a history of abuse or neglect are at increased risk
of abusing their children (Straus, 1994), while the age of the predominant parent
has also been found to be a risk factor for maltreatment (a younger age is associated with greater risk) (Cadzow, Armstrong, & Fraser, 1999). Other parental factors
that increase the risk for maltreatment include living in poverty, having an income
below $15,000, and being a single parent (Chance & Scannapieco, 2002; Sedlak
& Broadhurst, 1996). Parents who have a lower level of education and those with
an authoritarian or coercive parenting style are at higher risk for abusive behavior
(Cadzow et al., 1999). As much as 80% of cases of child maltreatment involve parent
substance abuse (Scannapieco & Connell-Carrick, 2004). Parents who are struggling
with their own mental health or psychiatric issues (depression, withdrawal, anger, personality disorders) are at significantly higher risk for maltreatment (Berliner & Elliott,
2002; Ferrara, 2002), while other personal problems, such as low self-esteem, lack of
self-concept, loneliness, and lack of impulse control under stress, have all been associated with increased risk for maltreatment (Coohey, 1996; Faust, Runyon, & Kenny,
1995).
Protective factors Protective factors in families that can buffer maltreatment include
marital and financial stability, and having at least one supportive adult in an otherwise
hostile environment (Dutton, 1998; Wolfe, 1999). Parents who have an understanding of appropriate developmental milestones (e.g., a toddler saying “No” is more
likely an assertion of independence rather than willful non-compliance) are less likely
to maltreat their children (Cicchetti & Lynch, 1995), while those who manage their
home with routines, planning, and consistency are more likely to avoid the stress, conflict, and chaos associated with more abusive environments (Wolfe, 1999). Having a
sibling may also be protective for school-age children and serve as an additional buffer
from stress in high conflict families and as a source of support throughout adolescence
(Caya & Liem, 1998; Campbell, Connidis, & Davies, 1999).
Prevention and intervention for child maltreatment
Prinz, Sanders, Shapiro, Witaker, and Lutzker (2009) suggest two reasons why high
rates of child maltreatment and referrals for alleged maltreatment “likely represent only
Child Maltreatment and Self-Injurious Behaviors
315
the tip of the iceberg in terms of parenting problems and child adversity,” including
the fact that many cases are not reported, and many “coercive or inadequate parenting
practices” may not meet criteria for abuse, but can still have significant negative outcomes for child development (p. 1). In their discussion of the continuum of emotional
sensitivity and expression, Wolfe and McIsaac (2011) suggest an approach to distinguishing between poor/dysfunctional parenting and emotionally abusive/neglectful
parenting, by considering the nature, frequency, and intensity of practices and outcomes. For example, a positive and healthy parenting approach would be one that
entailed positive emotional expressions (joy); interactions that are positive and supportive; consistency across situations; and clear rules and discipline that is moderate
with emphasis on behavioral methods, such as time outs, or temporary removal of
privileges. Poor and dysfunctional parenting would be evident in rigid/inflexible emotional responses; inconsistent patterns that do not balance the need for independence
and dependence; and the use of unclear rules, and coercive methods of disciplining
that confuse and upset the child. Emotionally abusive or neglectful parenting practices
would include: placing conditions on parental love; demonstrating ambivalent feelings
towards the child; rejecting the child’s bids for attention; responding unpredictably
to the child and often with high expressed emotion; and the use of coercive, cruel,
and harsh controls that threaten and frighten the child (Wolfe & McIsaac, 2011,
p. 807). Wolfe and McIsaac (2011) suggest that viewing parenting practices along
such a continuum provides the opportunity for the implementation of a public health
model for educating parents about healthy and positive parenting practices. In this
way, primary or secondary prevention programs can increase parent awareness of such
elements as balancing demandingness with support and encouragement in a consistent
approach that uses sound behavioral practices to discipline inappropriate and reward
appropriate behaviors (e.g., the Incredible Years program; Webster-Stratton, Reid, &
Stoolmiller, 2008). For those parents who were identified as emotionally maltreating
their children, tertiary prevention programs should focus on programs that have been
successful with high-risk populations, such as the Triple P Positive Parenting Program
(Prinz et al., 2009) and the Nurse-Home Visiting Program (MacMillan et al., 2009).
A parent’s inability to control his or her anger when disciplining a child can contribute to the potential for harsh actions that could result in abuse (Mammen, Kolko,
& Pilkonis, 2000). Research has focused on the parent’s maladaptive cognitions and
negative attributional bias about the child’s behaviors and/or inappropriate and unrealistic expectations that can result in increasing anger and aggressive responses (Bugental et al., 2002; Pidgeon & Sanders, 2009).
Dysfunctional or poor parenting practices, including coercive and punitive practices
that can be physically or emotionally abusive, place a child at increased risk of abuse,
while the promotion of and education in healthy and positive parenting practices
may be the most salient feature of programs for preventing abuse (Black, Heyman,
& Slep, 2001). Based on social learning theory, several prevention and intervention
programs have been developed to increase the use of positive parenting practices.
These have achieved positive results whether delivered in the home or community
(McNeil, Eyberg, Eisenstadt, & Newcomb, 1991), and have been demonstrated to
have long-term benefits (Long, Forehand, Wierson, & Morgan, 1994).
The Triple P Positive Parenting Program The Triple P program was developed
by Sanders (2008) and colleagues at the University of Queensland. The program has
been demonstrated to be effective in increasing parent competence and reducing child
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Clinical and Educational Child Psychology
behavior problems, in different cultures, globally (de Graaf, Speetjens, Smit, de Wolff,
& Tavecchio, 2008; Nowak & Heinrichs, 2008).
Sanders and Pidgeon (2011) discuss a derivation of the Triple P program, the
PTP, suitable for universal and targeted populations, which has been tailored to
meet the needs of parents at risk of abusing their children. The program targets
three areas that have been identified in at-risk and abusive parents: (i) parents’ angerintensifying attributional style for their child’s negative behaviors; (ii) parents’ angerjustifying style for their negative parental behavior; and (iii) parent anger management
deficits. Participants attend four two-hour group sessions where they learn and practice
strategies for reframing their maladaptive thoughts, with the goal of enhancing their
positive attributions about the parent–child relationship and reducing anger-related
behaviors.
Prinz et al. (2009) conducted a study of the effectiveness of the Triple P program
in 18 counties across the United States. Families were randomly assigned to the Triple
P program or to a service-as-usual control. Results revealed that the use of empirically
supportive parenting intervention practices resulted in positive prevention for all three
populations addressed: substantiated child maltreatment, out of home placements,
and child maltreatment injuries.
Self-injurious behaviors
Definition and prevalence rates
Terms such as “deliberate self-harm,” “self-mutilation,” “non-suicidal self-injury,” or
“cutting” refer to acts of self-injurious behavior not associated with suicidal intent.
Simeon and Favazza (2001) suggest four categories of self-injury: stereotypic (repetitive and dissociative type behaviors that may occur in the course of pervasive developmental disorders); major (infrequent but significant acts of self-mutilation that may
accompany a psychotic episode); compulsive (frequent and ritualistic behaviors such
as trichotillomania); and impulsive (deliberate attempts at self-mutilation often with
the intention of relieving tension). Lloyd-Richardson, Perrine, Dierker, and Kelley
(2007) suggest the use of the term non-suicidal self-injury (NSSI) for these behaviors, to distinguish between these behaviors and those involving suicidal intent; that
is, suicidal self-injury (SSI).
Prevalence rates Prevalence rates in England and Australia have been reported as
between 6% and 7% (Laukkanen et al., 2009); however, Ross and Heath (2002)
report rates as high as 13.9% in a community sample of students, especially girls,
admitting to self-mutilation. A meta-analysis of 128 population-based studies found
approximately 13% of youth report engaging in acts of self-injurious behaviors, while
20–30% also admitted to having suicidal thoughts (Evans et al., 2005). In a large
population-based study of over 4000 Finnish adolescents, Laukkanen et al. (2009)
found a lifetime prevalence rate of 11.5% for self-cutting, with both the prevalence
rate and frequency of cutting significantly higher in females than males. Jacobson and
Gould (2007) report rates for adults engaging in NSSI to be between 1% and 4%, while
adolescent rates range from 13% to 23%. Some studies show a significant proportion
of those engaging in NSSI are female (Csorba, Dinya, Plener, Nagy, & Páli, 2009;
Child Maltreatment and Self-Injurious Behaviors
317
Laukkanen et al., 2009), while other studies report no gender differences (Hilt, Nock,
Lloyd-Richardson, & Prinstein, 2008; Muehlenkamp & Gutierrez, 2004).
Characteristics and populations at risk for self-injury
Although self-cutting is the most common form of self-injury, other forms of NSSI
exist, including: scratching, burning, ripping or pulling hair or skin, swallowing toxic
substances, bruising, and breaking bones. Although characteristics vary widely, adolescents are the most likely to self-injure and two potential trajectories have been
identified: course persistent, NSSI which begins in early childhood and continues into
adulthood; and adolescence-limited, NSSI which begins in early adolescence and then
terminates at the end of adolescence (Nixon, Cloutier, & Aggarwal, 2002).
Child maltreatment and self-injury A growing body of research has linked NSSI
to child maltreatment, especially childhood sexual abuse (Aglan, Kerfoot, & Pickles,
2008; Briere & Gil, 1998; Yates, Carlson, & Egeland, 2008), and multiple maltreatment (sexual abuse and emotional neglect (Dubo, Zanarini, Lewis, & Williams,
1997); sexual abuse, physical abuse, and witnessing violence (Weiderman, Sansone, &
Sansone, 1999)). When viewed within a maltreatment context, NSSI can be seen as a
possible compensatory strategy for emotion regulation that has gone awry, becoming a
reactive pathway that responds to trauma at a neurobiological level through excitatory
and inhibitory processes involved in self-injury (Yates, 2004, 2009). In a healthy environment, secure attachment provides young children with the opportunity of learning
how to regulate their emotions effectively. However, in abusive situations, children
neither learn how to self-soothe, nor have their feelings validated, and may develop a
sense of dissociation or “psychic numbness” as a result (Rodriguez-Srednicki, 2001).
Furthermore, maltreatment in childhood has also been related to negative feelings of
self-worth, self-blame, and self-criticism that have all been related to increased risk for
self-injury (Gratz, 2006).
Childhood maltreatment has been related to self-injury directly and indirectly, with
neglect surfacing as either the single most significant predictor of self-injury (van der
Kolk, Perry, & Herman, 1991), or predictive of negative feelings of self-worth, selfblame, and self-criticism and increased risk for self-injury (Gratz, 2006). Yates (2009)
suggests that chronic stress caused by maltreatment may contribute to alterations in
the neurobiological and physiological systems that contribute to self-injury, especially
the limbic–hypothalamic–pituitary–adrenal (LHPA) axis responsible for the regulation
of chronic, long-term stress responses, and the norepinephrine-sympathetic-adrenalmedullary (NE-SAM) which regulates acute stress responses. Children who are maltreated demonstrate erratic flight or fight responses which result in increased depression, anxiety, suicidal ideation, and tendency to self-injure (Novak, 2003). Childhood
maltreatment has also been associated with reduced activity in the frontal cortex,
responsible for planning and managing responses (Kaufman & Charney, 2001).
Clinical populations and self-injury Csorba et al. (2009) studied 105 outpatient
adolescents (28 males, 77 females) between the ages of 14 and 18, who admitted to
engaging in NSSI. In this sample, cutting or scratching was the most common form of
NSSI, 60% suffered from a major depressive episode (current or in the past), and twothirds practiced the impulsive type of NSSI. Csorba et al. (2009) support suggestions
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made by Favazza (1999) that some individuals (in this case, about one-third of the
clinical sample) tend to ruminate or brood about NSSI for some time and engage in
rituals surrounding the act.
Nock (2009) proposes a model of NSSI to account for etiology and maintenance
based on intrapersonal factors (high physiological arousal in response to aversive stimuli and tendencies to avoid or escape aversive stimuli) and interpersonal factors (issues
in social problem solving and communication). Within this context, NSSI can serve
many functions as explained by different theories, including: social learning theory
(contagion response), self-punishment, social signaling (communicating one’s distress to others in a visual and graphic way), pain analgesia, and implicit identification
(emotion regulation becomes associated with NSSI).
Disorders that have been linked to NSSI include: borderline personality disorder,
post-traumatic stress disorder (PTSD), depression, eating and substance use/abuse
disorders and anxiety (Dyer et al., 2009; Yates, 2004).
Other risk factors Laukkanen et al. (2009, p. 25) found that adolescents who engaged
in self-cutting behaviors were more likely to also engage in more frequent “alcohol
consumption, drug abuse, sniffing, cannabis, daily smoking, and use of other illegal
drugs.” From a psychosocial perspective, having no friends, being aggressive, or experiencing symptoms of depression or somatic complaints were risk factors, while having both parents living together was a protective factor. Negative affective states that
motivated adolescent self-injury included: feeling a need to hurt the self, depression,
negative feelings towards the self, isolation, and need for distraction (Laye-Gindhu &
Schonert-Reichl, 2005).
Whitlock, Powers, and Eckenrode (2006) investigated the role of the internet
in adolescent self-injury and found hundreds of message boards devoted to selfinjury. Although some of the responses provided a supportive network for those
who self-injure, the researchers expressed concern about vulnerable youth’s exposure
to a culture where self-injury is normalized, and information is available regarding
new types of self-injury and purchasing paraphernalia that identify individuals as a
member of a “cutting club.” The authors conclude that “like other social environments
(schools, families or neighbourhoods) the Internet plays a powerful role in shaping
opportunities for adaptive and maladaptive social interaction” (Whitlock et al., 2006,
p. 416).
Intervention and treatment
Web-based social support networks Since adolescence is a peak time for selfinjurious behaviors, and the majority of youth use the internet for social networking
(Whitlock et al., 2006), there has been an increased interest in the possibility of
integrating internet social support networks in a therapeutic way for youth with selfinjurious behaviors.
In their review of articles about self-injurious behaviors and web-based social networking, Messina and Iwasaki (2011) discuss the pros and cons of using web-based
centers for therapeutic purposes. While some report these discussions are beneficial
in reducing the incidents of self-harm (Murray & Fox, 2006), other sites can actually
trigger episodes of self-harm (Adler & Adler, 2007). Whitlock, Lader, and Conterio
(2007) provide guidelines to assist psychotherapists in integrating the internet into
Child Maltreatment and Self-Injurious Behaviors
319
their therapy, including the use of questions to determine frequency and nature of
usage. Whitlock et al. (2007) also recommend websites affiliated with more quality
controlled sources such as WebMD, LifeSIGNS, and SIARI. However, future research
is recommended to determine the efficacy of web-based support networks.
Dialectical behavior therapy (DBT) DBT was initially introduced by Linehan,
Armstrong, Suarez, Allmon, and Heard (1991) to treat adults with borderline personality disorder (BPD) who engage in high-risk behaviors such as suicide attempts
and other self-injurious behaviors. Linehan et al. (1991) use biosocial theory to explain
the underlying forces that cause self-injurious behaviors that result from a combination of internal forces (problems in the identification and control of emotions) and
external forces such as a history of having one’s emotions punished, trivialized, or
ignored. The DBT method is an eclectic combination of cognitive-behavioral techniques (CBT), humanistic, and modern psychodynamic approaches. In addition to
individual therapeutic sessions focused on the client–therapist relationship supported
in an environment fostering empathy and self-affirmation, clients are also instructed in
CBT practices that focus on individual homework assignments and in group sessions
such as social skills building groups (Comer, 2010).
DBT has used been successful in the treatment of adults and is the treatment
of choice for BPD. More recently, DBT was adapted for use with suicidal adolescents (Rathus & Miller, 2002) and has subsequently been successful in reducing
self-injurious behavior in youth in a number of investigations (Katz, Gunasekara,
Cox, & Miller, 2004; Sunseri, 2004).
Lang and Sharma-Patel (2011) suggest that the success of the DBT approach lies
in educating the client that although NSSI behaviors provide temporary relief from
immediate tension, this behavior is part of a cycle that comes at a high price of increased
long-term dysfunction. Integrating DBT components of acceptance (validation of the
intensity of distress) and change (learning new techniques to reduce stress in a healthy
way) provide the necessary balance to address and alleviate the underlying process.
Trauma-focused cognitive behavioral therapy (TF-CBT) Exposure therapies
have long been associated with treatment for anxiety disorders where increased tensions are likely to elicit avoidant response patterns (Cohen, Deblinger, Mannarino, &
Steer, 2004). Within this context, TF-CBT for self-injury engages individuals in the
identification of a hierarchy of stressors associated with self-injury. Future research
will determine the efficacy of this treatment method in the reduction of NSSI. There
is increasing support for the use of TF-CBT for NSSI (DeRosa et al., as cited in Lang
& Sharma-Patel, 2011; Briere & Scott, 2006).
Acceptance and commitment therapy (ACT) The underlying assumptions of ACT
are similar to those of DBT and TF-CBT, and focus on acceptance of feelings (rather
than avoidance), and positive movement towards healthy alternatives. Using mindfulness as a process, ACT engages youth to focus on the pain (acceptance and tolerance)
that accompanies memories rather than avoidance through self-injury. There is some
evidence to support the use of ACT for NSSI (Powers, Vording, & Emmelklamp,
2009).
320
Clinical and Educational Child Psychology
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13
Trauma and Trauma Disorders
Chapter preview and learning objectives
Child and adolescent trauma disorders: an introduction
Type I and Type II trauma
Poly-victimization
Developmental trauma disorder
Traumatic stress disorders: a developmental perspective
Reactive attachment disorder (RAD)/disinhibited social
engagement disorder
Definition
Nature and course
Etiology and prevalence
Assessment and treatment
Post-traumatic stress disorder
Definition: PTSD in children and adolescents
Definition: PTSD in preschool children
Nature and course
Etiology and prevalence
Assessment and treatment/intervention
References
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Chapter preview and learning objectives
The discussion of childhood disorders in Chapter 6 introduced the adjustment disorders which the DSM describes as a psychological response to an identifiable stressor
(or stressors) that results in significantly distressing, emotional, and behavioral reactions (APA, 2000). The response can be distressing, is often more intense than would
be expected, and can result in significant impairment in functioning. However, the
response is a temporary one, occurring within three months of the stressful situation,
but lasting no longer than six months after the stressor is removed.
Clinical and Educational Child Psychology, First Edition. Linda Wilmshurst.
© 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.
Trauma and Trauma Disorders
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Distress
When capacity to cope with existing demands, exceeds our ability to cope, then
Stress becomes Distress.
Children who experience distress resulting from chronic interpersonal trauma often
do so within the context of an environment where exposure to adverse early life
experiences includes caregivers who do not provide security and a safe haven from
harm. In this chapter, severe forms of stress-related disorders are introduced that are
triggered by traumatic situations or events that result in symptoms of re-experiencing
the event, attempts to avoid potential triggers of the event, and heightened agitation
and arousal. These symptoms can be acute, lasting for less than one month, as in acute
stress disorder, or more pervasive, lasting for more than a month and potentially for
years, as can be the case with post-traumatic stress disorder (PTSD). Prior to discussing
the traumatic stress disorders, the focus will be on reactive attachment disorder, a
severe disorder with onset prior to age five which can develop in response to various
forms of maltreatment and results in disturbances in the child–parent attachment
relationship.
Child and adolescent trauma disorders: an introduction
Costello, Erkanli, Fairbank, and Angold (2002) conducted a longitudinal survey of
1420 children and adolescents from middle childhood through adolescence who
were living in western North Carolina regarding exposure to traumatic events. In
this sample, one in four children reported that they had been exposed to a “high
magnitude” traumatic event (an extreme stressor, such as witnessing or hearing about
the death of a loved one, a serious illness, a serious accident, a natural disaster, a fire, or
being a victim of violence, rape, or sexual abuse) by 16 years of age, while one-third
had been exposed to a “low magnitude event” (such as a new child in the home,
pregnancy, parental separation/divorce/new parental figure, or parent arrest) in the
previous three months.
It has long been suspected and more recently confirmed that childhood maltreatment can have a profound impact on development, extending into the adult years. In
Chapter 12, the focus was on different types of maltreatment, as well as the potential
outcomes, risks, and protective factors. In this chapter there will be more discussion
about the nature and outcomes of multiple maltreatment, as well as the nature of the
maltreatment in terms of Type I and Type II trauma.
Type I and Type II trauma
Terr (1991) suggested that childhood trauma could be best conceptualized as two
distinct forms of trauma: Type I traumas which consist of single event incidences;
and Type II traumas which refer to chronic and long-term victimization where the
child is exposed to a repeated traumatic event, such as repeated physical, sexual, or
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emotional abuse, or prolonged neglect. Within this framework, Terr (1991) proposed that symptoms and outcomes would be more severe (including dissociation
and emotional numbing) for children who experienced Type II trauma, and may
ultimately result in the development of personality disorders in the future. Subsequently, researchers have provided support for Terr’s theory, demonstrating that children exposed to chronic physical or sexual abuse were at greater risk for depression
and schizophrenia, relative to peers who experienced Type I trauma (Kiser, Heston,
Millsap, & Pruitt, 1991), as well as for the development of borderline personality
disorder as adults (Sansone, Sansone, & Gaither, 2004).
More recently Allen and Lauterbach (2007) found that adults who experienced
Type I or Type II trauma as children rated significantly higher on the neuroticism
(symptoms of anxiety and depression) and openness to new experiences subscales of the
brief Big Five Personality Measure (Goldberg, 1992) relative to controls, while those
who experienced Type II trauma also scored significantly higher on the neuroticism
scale than those who experienced Type I trauma. The authors suggest that while
endorsement of the neuroticism scale was not unexpected, scoring high on the openness to new experiences scale may increase the chances of individuals engaging in risky
behaviors, which would make them more vulnerable to revictimization in the future.
Poly-victimization In addition to looking at outcomes related to experiencing single
versus repeated trauma, studies have also investigated the impact of exposure to multiple different types of abuse. Finkelhor, Ormrod, and Turner (2007) surveyed 2000
children (aged two to 17 years) through random digit dialing, and found that 70% of
respondents (children, or parents of younger children) reported at least one adverse
and stressful incident of victimization, while 64% also admitted experiencing a different type of victimization. The mean number of victimizations in this sample was 2.8
episodes. Continued data collection with a national sample of 4549 children (aged 0
to 17 years) yielded the following prevalence rates for poly-victimization: close to 66%
reported more than one type of victimization; 30% experienced five or more different types; and 10% admitted to 11 or more different forms of victimization (Turner,
Finkelhor, & Ormrod, 2010). The authors conclude that poly-victimization is more
significantly related to trauma symptoms than Type II trauma (repeated victimization
of a single type) and emphasize the need to recognize the impact of experiencing
multiple victimizations and the role that cumulative trauma can have on development
in all areas.
Determining the number of episodes of victimization is important, since research has
shown that adult outcomes for multiple victimization in childhood are associated with
more severe and negative consequences (Marx, Heidt, & Gold, 2005). Researchers
have also investigated the likelihood of certain types of maltreatment increasing the
risk for other forms of maltreatment. Exposure to domestic violence has been linked to
general child maltreatment in 30–60% of cases, and to child physical abuse in 45–70%
of cases (Edleson, 1999; Margolin, 1998).
In their development of Practice Parameters for the Assessment and Treatment of
Children and Adolescents with Posttraumatic Stress Disorder, the American Academy of
Child and Adolescent Psychiatry (AACAP, 2010) has cautioned that although children
may present with behavioral problems or may be referred due to their exposure to a
single traumatic event, practitioners should be cognizant that other traumatic events
may be at the core of the problem, even if these are not immediately discernible.
Trauma and Trauma Disorders
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In their study of poly-traumatic victims, Kira, Lewandowski, Somers, Yoon, and
Chiodo (2012) found that for individuals who experienced Type I trauma, numbness/dissociation provided a protective effect against hyperarousal and re-experiencing
which can damage IQ performance. However, for youth who experienced cumulative
traumas, negative effects on information processing were evident in all areas of IQ
functioning (memory, perceptual reasoning, verbal comprehension, and processing
speed).
Developmental trauma disorder Recognizing the impact of interpersonal trauma on
young children and the implications this has for psychological well-being, van der
Kolk and Pynoos (2009) have advocated for the establishment of a new classification
for children, developmental trauma disorder (DTD), which they proposed should
be added to the DSM-V. In their proposal, DTD is conceptualized as encompassing
facets of post-traumatic stress disorder (PTSD), but providing a more appropriate
and comprehensive description of symptoms that children experience resulting from
interpersonal trauma (often involving multiple victimizations) and the disruption of
caregiver support systems. The current diagnostic system does not recognize symptoms unique to children, nor post-traumatic sequelae, such as disturbances in affect
regulation, attention and concentration, impulse control, aggression, and risk taking
that are not part of the criteria or characteristics associated with PTSD. As a consequence, deficiencies in the current diagnostic system often result in a lack of diagnosis,
inaccurate diagnosis, or inadequate diagnosis for traumatic disorders in children.
There is research support for the proposal put forth by van der Kolk and Pynoos
(2009). Cloitre et al. (2009) studied cumulative trauma in children and adults and
concluded that “exposure to multiple or repeated forms of maltreatment and trauma
in childhood can lead to outcomes that are not simply more severe than the sequelae
of a single incident trauma, but are qualitatively different in their tendency to affect
multiple affective and interpersonal domains” (p. 405). As a result of their findings,
Cloitre et al. (2009) suggest that DTD may provide a new way of classifying the
complex profiles produced by these traumatized children.
Traumatic stress disorders: a developmental perspective As it currently stands, there are
a number of options for classifying trauma disorders in children: traumatic attachment
disorders (reactive attachment disorder; inhibited and disinhibited types) and the traumatic stress disorders (acute and post-traumatic disorder). The current classification
system is in transition and there are many conceptual issues that are in the process
of being resolved that will likely impact how we classify stress disorders in the future.
There is consensus between the DSM and ICD that traumatic attachment disorders
can manifest in two different symptoms clusters: an inhibited type and a disinhibited
type. However, whether these two types represent two different disorders, or subtypes
of one disorder, is a point of contention.
As for the stress disorders, as has already been discussed, there is much controversy as to whether symptoms for post-traumatic stress disorder are broad enough
to encompass situations of multiple, poly-traumatic, and chronic stress conditions,
and whether the unique symptom constellations should be recognized with a more
appropriate classification, such as DTD (which was previously discussed) or disorders of extreme stress not otherwise specified (DESNOS, to be discussed shortly)
(Blaz-Kapusta, 2008; Ford, 1999; Herman, 1997; van der Kolk & Pynoos, 2009).
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Reactive attachment disorder (RAD)/disinhibited social
engagement disorder
Definition Historically, RAD first appeared in the third revision of the DSM (APA,
1980), and criteria were modified over the course of the next two editions. In the
current edition of the DSM (APA, 2000) reactive attachment disorder is described
as a marked disturbance in social relatedness with onset prior to five years of age,
and causing one of two predominant behavioral patterns, indicating one of two types
of RAD:
1. inhibited type: an excessively inhibited response to social interaction which might
be characterized by hypervigilant, ambivalent, or contradictory responses (e.g.,
approach/avoidance, resistance to being soothed, or frozen watchfulness);
2. disinhibited type: indiscriminate and diffuse social responses accompanied by
an inability to display selective and appropriate social affiliations (e.g., lack of
selectivity in attachment figures, or excessive familiarity with individuals who have
minimal contact).
The disorder is not due to an intellectual disability or autism spectrum disorder, and
is manifested in response to “pathogenic care” which may be evident in persistent
neglect and disregard for the child’s basic, emotional needs, or basic physical needs;
or frequent and repeated changes in primary caregiver, resulting in poor formation
of normal and stable attachments. The two forms of RAD have been identified in
populations of maltreated, and institutionalized or formerly institutionalized, children
(Rutter et al., 2007; Smyke, Dumitrescu, & Zeanah, 2002; Zeanah et al., 2005).
A controversial question is whether the two forms represent variants of one disorder
or if they are best represented as two distinct disorders. While the current DSM
considers these responses as two subtypes of the same disorder, the ICD conceptualizes
the variants as two distinct disorders: reactive attachment disorder (RAD), which aligns
with the inhibited pattern in the DSM, and disinhibited attachment disorder (DAD)
which aligns more with the indiscriminately social disinhibited type of RAD.
In the proposed DSM-V, it has been recommended that the two be recognized as
separate disorders, which is in keeping with the current ICD classification: namely,
reactive attachment disorder of infancy or early childhood (RAD), and disinhibited
social engagement disorder (DSED). In addition to conceptually altering the way that
RAD is perceived, the proposed changes also suggest a more comprehensive list of
symptoms that match findings from empirical research. With these changes in mind
the following suggestions for criteria have evolved.
Reactive attachment disorder of infancy or early childhood (RAD) This disorder has onset between nine months and five years of age and describes children who
in times of distress manifest a marked disturbance in attachment, rarely seeking out
the caregiver as a source of comfort and instead demonstrating a consistent pattern of
inhibited and emotionally withdrawn behavior, displaying two of the following characteristics: lack of emotional responsiveness to others; low positive affect; or episodic and
random responses to caregivers that demonstrate sad, irritable, or fearful behaviors.
Exclusionary criteria require that the above characteristics are not the result of autism
spectrum disorder.
Trauma and Trauma Disorders
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Precipitating conditions A diagnosis of RAD requires one of the following cardinal precipitating conditions: neglect of care and disregard for basic emotional
needs; neglect of basic physical needs; or adverse living conditions, including frequent changes of primary caregivers (different caregivers, different foster placements),
or care provided in an institution or setting with a large child-to-caregiver ratio.
Disinhibited social engagement disorder (DSEG) Children in this category
demonstrate an indiscriminate and active effort to engage with unfamiliar adults,
involving two of the following four conditions: a lack of shyness or inhibition in
approaching unfamiliar adults; a lack of social referencing or checking back with the
caregiver after wandering off; a lack of hesitation in venturing off with a stranger;
or engaging in social solicitation that demonstrates a disregard for social boundaries
(overly familiar, verbally or physically). An exclusionary criterion for DSEG is that the
above characteristics are not better accounted for by ADHD.
Precipitation conditions: The child’s early history would be seen as responsible for
the development of the disorder by including one of the three precipitating conditions,
as noted for RAD, above. Gleason et al. (2011) provide data from their longitudinal
studies of children adopted from institutions (e.g., the Bucharest Early Intervention
Project) that support conceptualizing two separate forms of RAD. The researchers
found that 17.6% exhibited the socially disinhibited version of RAD/DSEG at
54 months post-institutionalization, while 4.1% exhibited the emotionally withdrawn/
inhibited version of RAD. The authors suggest support for two different versions of
RAD, in keeping with the proposed revision.
Differential diagnosis: RAD and disorganized/disoriented attachment: Main and
Solomon (1990) describe a disorganized/disoriented attachment pattern that infants
display in the strange situation experiments (Ainsworth, Blehar, Waters, & Wall, 1978)
which has been associated with child maltreatment and/or parent psychopathology
(Lyons-Ruth & Jacobvitz, 1999). In this pattern, children demonstrate a number of
odd behaviors when the caregiver leaves or returns to the laboratory setting. However,
in this case, the impairment is in the attachment relationship itself and may not be
evident in other areas, unlike RAD which influences the child’s ability to establish
normal social relationships. While children with disorganized/disoriented patterns
are at higher risk for aggression towards peers and externalizing behaviors beginning
in preschool (Troy & Sroufe, 1989) and persisting into elementary school (Renken,
Egeland, Marvinney, Mangelsdorf, & Sroufe, 1989), children with reactive attachment
disorders may also demonstrate significant internalizing problems, and withdraw from
contact with others.
Nature and course Given that attachment disorders derive from situations of
“pathogenic care” involving emotional or physical maltreatment or some form of
institutionalized care, it is not surprising to see that many children meet criteria for
both an attachment disorder and PTSD (Hinshaw-Fuselier, Boris, & Zeanah, 1999).
As will be discussed at greater length later in the chapter, symptoms of PTSD can
manifest in different ways during the course of development; however, one common
symptom of PTSD in young children is “emotional numbing” (Carrion, Weems, Ray,
& Reiss, 2002) which can be attributed to chronic fatigue or exhaustion due to pervasive and on-going experiencing of high levels of arousal (Weems, Saltzman, Reiss, &
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Carrion, 2003). Children are also more likely to be exposed to Type II trauma, which
involves the repeated exposure to abuse over time, than Type I trauma, like a natural
disaster or traumatic event which occurs once (Terr, 1991). Given that the attachment
disorders represent exposure to Type II trauma, symptoms of PTSD such as emotional
numbing can be seen in children with the inhibited form of the attachment disorder.
The inhibited type of attachment disorder represents an extreme form of withdrawal
and inhibition that has developed in the absence of an attachment to a caregiver and
is related to severe forms of maltreatment and neglect. Other characteristics of the
disorder that have been found in the literature include: a failure to seek out or respond
to comfort when distressed, flat affect, unpredictable bouts of irritability or fearfulness,
low levels of social or emotional reciprocity, and poor emotion regulation (Smyke,
Dumitrescu, & Zeanah, 2002; Tizard & Rees, 1975; Zeanah et al., 2005). While those
with the inhibited type have been found to be very responsive to enhanced caregiving,
those who are socially disinhibited may develop attachments when caregiving becomes
more positive and stable but nevertheless still tend to exhibit socially inappropriate
and disinhibited responses to other unfamiliar adults (Zeanah & Smyke, 2008).
Research has provided several documented cases of attachment disorders that
conform to descriptions of the socially disinhibited form of attachment disorder,
including: tendencies to approach strangers and unfamiliar adults without reservation;
a lack of hesitation in venturing off with strangers; and tendencies to ignore
appropriate social boundaries in their interactions with adults, while soliciting social
contact by seeking close proximity to unfamiliar adults and being intrusive, verbally
or physically (O’Connor, 2002; O’Connor & Zeanah, 2003; Zeanah, Smyke, &
Dumitrescu, 2002).
Etiology and prevalence
Etiology Researchers have investigated the relationship between early maltreatment/deprivation and attachment theory and have suggested several possible causes
for negative outcomes, including: perinatal exposure to toxins; lack of goodness of
fit between child and parent temperament; and poor or dysfunctional parenting practices (Kemph & Voeller, 2008). For example, Lyons-Ruth, Bureau, Riley, and AtlasCorbett (2009) found that the indiscriminate and uninhibited form of attachment
disorder was exhibited by high-risk infants only if they also experienced maltreatment or if their mother was hospitalized for psychiatric problems. Lyons-Ruth et al.
(2009) suggest that the attachment disorder and subsequent indiscriminant behaviors
resulted from the disruption in emotional caregiving. According to Hardy (2007, p.
28), an inability to develop a consistent internal working model (IWM) based on
secure affective interactions can result in altering “neurological development and lead
to the creation of neural networks (particularly in the right hemisphere) that will
influence the infant’s personality and relationships with others throughout life.”
Hariri (2002) suggests that early maternal deprivation may also alter brain development, by causing overactivity of the hypothalamic–pituitary–adrenal (HPA) system
resulting in the production of elevated levels of the stress hormone cortisol. Support
for HPA activation is found in reports of increased levels of cortisol in traumatized
infants when they are reunited with their caregivers (Nachmias, Gunnar, Mangelsdorf,
Parritz, & Buss, 1996). In addition, Barr et al. (2003) suggest that some children
may be more vulnerable to dysfunctional parenting practices due to their biological
Trauma and Trauma Disorders
335
make-up, such as possessing the 5-HTT short allele of the serotonin transporter
polymorphism associated with heightened activity and arousal of the amygdale and
cortisol systems.
Prevalence In their follow-up studies of Romanian children, O’Connor (2002) and
Zeanah (2000) found that the disinhibited type was most prevalent among those who
were adopted out of the institutional setting, while Smyke, Dumitrescu, and Zeanah
(2002) reported that the inhibited type was most prevalent among those children who
remained at the orphanage. In addition, the disinhibited/indiscriminate behaviors
associated with the socially disinhibited attachment disorder persisted for years, even
if the children eventually established a secure attachment with their adopted parent
(Chisholm, 2009; O’Connor, Marvin, Rutter, Orlick, & Britner, 2003).
Gleason et al. (2011) report the following prevalence rates for the two forms of
attachment disorders found in their longitudinal sample of previously institutionalized children: social/disinhibited children at baseline (31.8%), 30 months (17.9%),
42 months (18%), and 54 months (17.6%); and withdrawn/inhibited children at
baseline (4.6%), 30 months (3.3%), 42 months (1.6%), and 54 months (4.1%).
Assessment and treatment
Assessment Diagnosis of RAD has been problematic in the past because of the
high degree of overlap in symptoms of RAD with other childhood disorders, such
as ADHD, anxiety disorders, and PTSD (Balbernie, 1997; Kemph & Voeller, 2008)
or in situations of less severe symptom presentations (O’Connor, Rutter, Beckett,
Keaveney, & Kreppner, 2000).
In the absence of a suggested protocol for assessing RAD, Sheperis et al. (2003)
suggest a test battery, including evaluation of intelligence, obtaining a developmental
and medical history, conducting interviews and observations, and completion of a
number of behavioral rating scales, such as the Child Behavior Checklist (Achenbach
& Rescorla, 2001).
More recently, Thrall, Hall, Golden, and Sheafer (2010) evaluated two screening
measures designed to aid in diagnosing RAD: the Reactive Attachment DisorderChecklist (RAD-C; Hall, 2007) and the Relationship Problems Questionnaire (RPQ;
Minnis, Rabe-Hesketh, & Wolkind, 2002) which has been used in Great Britain to
aid in the diagnosis of RAD. Results revealed that scores on the RPQ and RAD-C
discriminated significantly between children with RAD and the control groups, both
statistically and clinically.
The American Association of Child and Adolescent Psychiatry (AACAP, 2005,
p. 1214) has made several suggestions for the assessment of children with RAD,
including: direct observations of the child with primary caregivers and unfamiliar
adults; obtaining a complete history of the child and caregivers; reporting of maltreatment to the appropriate authorities; accessing the safety of the current placement;
and appropriate referrals for assessments of developmental delays, language delays, or
medical concerns.
Treatment The AACAP (2005) recommends that treatments be based on the individual needs of the child, including caregiver education when needed, and recognizing that “the building blocks of secure attachment are interactive moments” where
the caregiver needs to be attuned to the child’s needs, in order for the child to
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develop “an internal sense of security” (AACAP, 2005, p. 1215). The AACAP (2005)
suggests that service delivery can occur at three levels: working through the caregiver;
working with the child and caregiver dyad; or working individually, with the child;
and that adjunct therapeutic interventions should be used if aggression or opposition/defiance are issues. The AACAP (2005) cautions strongly against the use of
“non-contingent physical restraints or coercion (Therapeutic Holding) or reworking
the trauma (Rebirthing Therapy) since these practices have no empirical support and
have in fact resulted in serious harm, including death” (p. 1216).
Failure to develop a sense of “affective sharing” could negatively influence the
development of self-awareness and other awareness which usually develops at about
18 months of age; however, an absence of shared emotional communication might
be the precursor to “shunning of sharing” or avoidance of a caregiver who causes
distress (Lyons-Ruth, 2008). In these cases, intervention would be directed towards
rebuilding emotional and affective channels of communication and sharing. Securely
attached children are better able to regulate their emotions and manage physiological
stress responses than those with insecure attachments, while those with disorganized
attachment have even greater dysregulation (Gunnar & Quevedo, 2007). Children
who are maltreated are over five times more likely to have insecure attachments
(Carlson, Cicchetti, Barnett, & Braunwald, 1989), while traumatic stress responses are
more often associated with traumatized children who have insecure attachments, likely
due to their inability to seek comfort from the caregiver (Lynch & Cicchetti, 1998).
According to Kemph and Voeller (2008, p. 174), repairing the damage resulting
from RAD requires an acknowledgement that some of these children may be “attachment resistant,” and enhancing their ability to develop social relationships may pose
a challenge that requires patience and practice and “many repetitions of appropriate
thoughts and behaviors over a prolonged period of time” in order to form “new
neuronal patterns” which may ultimately enable the child or adolescent to develop
socially meaningful relationships.
Hardy (2007) suggests that treatment focus on enhancing existing or creating new
attachment relationships and reducing problematic behaviors, while Corbin (2007)
stresses the need to foster secure attachments in the development of self-confidence.
Cornell and Hamrin (2008) suggest the need to provide psycho-educational and
psychotherapeutic supports that target primary attachment relationships and limit
exposure to multiple caregivers.
Chaffin et al. (2006) summarize the Task Force position of the American Professional Society on the Abuse of Children (APSAC) on attachment therapy, RAD,
and attachment disorder problems. In their document, similar to AACAP, they also
take a strong stand against the use of coercive “holding techniques” which have
no empirical basis and have even resulted in fatalities. Chaffin et al. (2006) suggest
that in addition to potential physical harm, the technique can also be psychologically
damaging to the child who is already feeling victimized, and would be subjected to
even further harsh and controlling tactics that would likely increase feelings of victimization and helplessness. As an alternative, empirically based behavioral training
programs have had an excellent success rate with child behavior problems, similar to
those demonstrated by children with attachment disorders. Examples of empirically
supported programs for behavior problems, some of which were discussed in Chapter
12, and in previous chapters, include: behavioral management training (BMT; Barkley,
1997); the Incredible Years (Webster-Stratton & Reid, 2003); the Triple P Program
(Prinz, Sanders, Shapiro, Witaker, & Lutzker, 2009; Sanders & Pidgeon, 2011), and
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parent–child interactive therapy (PCIT; Eyberg & Boggs, 1998), a program which
targets preschool children.
Buckner, Lopez, Dunkel, and Joiner (2008) selected BMT for their case study of
a seven-year-old girl with RAD. Results of their case study revealed that BMT was
successful in reducing problematic behaviors, and increasing compliance with caregiver
and teacher requests, as well as improving age-appropriate play with peers.
What is behavioral management training (BMT)?
BMT (Barkley, 1997) is a manualized 10-session program for caregivers
of school-age children. The program targets behavioral problems (compliance, defiance, attention/concentration), and provides parents/caregivers
with psycho-educational information about precipitating and maintaining
causes of behaviors, opportunities for practice sessions to enhance parenting
skills/effectiveness, and techniques to assist in developing a home-based reward
system.
Based on their investigation of neurological explanations of problems in selfregulation experienced by children with traumatic attachment histories, HuangStorms, Bodenhamer-Davis, Davis, and Dunn (2007) used EEG biofeedback to
instruct children in self-regulation to enhance attention, control impulses, and help
better manage their physiological and emotional arousal states. Initial results showed
a reduction in the majority of behavioral categories evaluated by the Child Behavior
Checklist (CBCL; Achenbach & Rescorla, 2001). Future research will provide more
insight into the efficacy of this neuro-feedback approach.
Interventions for children with RAD in the school system Children with a history of
disrupted attachment have not met key attachment goals (proximity, security, safety,
and self-regulation) and the school psychologist can assist in educating school personnel on ways to enhance the child’s sense of security. Schwartz and Davis (2006) suggest
furthermore that the school psychologist can help teachers understand the importance
of the student–teacher relationship in “providing a sense of safety and security and
enhancing self-regulation” that may “enable children to explore the environment,
regulate behaviors and emotions and join others in the process of learning” (p. 477).
Within the context of the school environment, Lieberman and Zeneah (1999) also
emphasize the need to use interventions that are child-specific and developmentally appropriate, and minimize emotional pressure and negative practices (scolding,
condemning).
Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) is also triggered by a stressor, the nature of
which is extreme, traumatic, and often life-altering. Examples of the types of trauma
include: natural disasters (floods, hurricanes, earthquakes), accidents (car wreck, being
struck by a car), wars, victimization, and witnessing or experiencing a life-threatening
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event. However, what constitutes a trauma for a child may be difficult to determine
since some events, although not violent or life-threatening, may still have traumatic
outcomes for children (such as inappropriate sexual touching). In addition, what is
traumatic may also differ by developmental level. Children who suffer from PTSD can
experience flashbacks, numbing, avoidance, heightened physiological arousal, and a
sense of a foreshortened future.
Definition: PTSD in children and adolescents The DSM currently defines PTSD as
a cluster of symptoms which develop in the aftermath of exposure to an extremely
traumatic episode or event. There are six criteria, the first of which contains two parts:
A1. the relationship between the individual and the event such that the person
is either directly exposed to an event, or has witnessed an event that is either
life-threatening, or results in serious injury to the person or others;
A2. the individual experiences a response of “fear, helplessness or horror” as a result.
Both criteria (A1 and A2) are required for a diagnosis of PTSD. However, for children,
the response (A2) may be one of “disorganized or agitated behavior” (APA, 2000,
p. 467).
The DSM groups the symptoms into three broad criterion clusters:
B. re-experiencing of intrusive thoughts and images;
C. avoidance and numbing; and
D. hyperarousal.
Symptoms from these clusters must be evident for more than a month and cause
significantly impaired functioning.
Re-experiencing Re-experiencing of the trauma can be invasive and intrusive,
unpredictable, and uncontrollable, and can result in significant anxiety and distress.
The diagnosis of PTSD requires one symptom from this cluster. This category includes
five symptoms, namely: recurring thoughts about the trauma; recurrent dreams; flashbacks; intense psychological distress; and intense physiological responses to triggers
or cues about the trauma.
Symptoms of re-experiencing in children
In children recurrent thoughts or images may appear as repetitive play, and
while they may experience nightmares, they may not be aware of how these
are related to the trauma. Dreams can have themes of monsters or rescue.
Flashbacks may appear as re-enacting parts of the trauma, while distress may
manifest in complaints of headaches and stomachaches. Research suggests that
re-experiencing might be one of the most prevalent symptoms of PTSD in
children of school age (Carrion et al., 2002; La Greca, Silverman, Vernberg, &
Prinstein, 1996).
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Avoidance and numbing Individuals with PTSD will attempt to avoid people,
events, or situations that might trigger thoughts or images of the traumatic situation.
This is often accomplished by physical distancing and emotional numbing. There is
usually a loss of interest in normal activities and a stunted perspective on the future.
The DSM requires three symptoms from a list of seven potential symptoms, namely:
avoidance of conversations about the trauma; inability to recall details about the
trauma; avoidance of activities associated with the trauma; loss of interest in normal
activities; restricted range of affect; detachment; and a sense of a foreshortened future.
Symptoms of avoidance and numbing in children
Children may avoid talking about the event or engaging in activities associated
with the event, or develop a sense of time skew which results in their inability to
recall trauma-related events in the correct sequence. Parents and teachers may
report diminished interest in activities and restricted range of affect. Although
emotional numbing is not typically one of the most prevalent symptoms in
children (Carrion et al., 2002), it has been observed at all developmental levels.
Increased agitation and arousal There may be evidence of interrupted sleep/
nightmares, difficulties concentrating/distractibility, and irritability or anger. There
are two symptoms required from a list of five problem areas: difficulty in falling or
staying asleep; problems with concentration/task completion; hypervigilance; exaggerated startle response; and angry or irritable outbursts. If symptoms subside within
a month, then a diagnosis of acute stress disorder is made instead of PTSD.
Symptoms of increased agitation and arousal in children
In addition to exhibiting symptoms of heightened arousal, disorganizat